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SMITHSONIAN DEPOSIT 



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a complete 



PRACTICAL WORK 



ON TI1K 



NATURE AND TREATMENT 



OF 



VENEREAL DISEASES, 



AND 



OftER AFFECTIONS 



OF THE 



GENITOURINARY ORGANS 



OF THE 

MALE AND FEMALE. 



ILLUSTRATED BY A GREAT NUMBER OF BEAUTIFULLY COLORED PLATES, AND MANY FINELY 

EXECUTED DELINEATIONS ON WOOD. 



BY HOMER BOSTWICK, M. D. 

ACTHOR OF " A TREATISE ON THE NATURE AND TREATMENT OF SEMINAL DISEASES," &.C., AC, tC. 



NEW YORK: 
PUBLISHED BY BURGESS, STRINGER & Co., 

1848. 



V 










Entered according to Act of Congress, in the year 1848, by Homer Bostwick, M. D. in the Clerk's Office of the District Court 
of the United States for the Southern District of New York. 



I 



PREFACE, 



There are no maladies to which the human family is liable, of deeper importance, 
either in a medical or moral point of view, than those arising from impure sexual 
intercourse. With their moral bearings, in a work of this nature, we properly can 
have nothing to do. As medical men, it is our business to look at disease merely 
as it affects life and health ; and our efforts are directed, not to the reformation of 
man's vicious propensities, but to the mitigation of his bodily sufferings. It is in 
this abstract sense that we write of venereal affections ; and it is in this sense that 
the student should address himself to their study. If his feelings are allowed to influ- 
ence his professional pursuits, his qualifications will necessarily be limited to those 
subjects that are most agreeable to his tastes. To become an enlightened practi- 
tioner, it is essential that he should be a liberal and ardent one ; and affections, 
in their nature repulsive to delicate sensibilities, must be regarded in no other light 
than as morbid phenomena of the living body. 

The whole business of the medical art, when we take alow view of it and regard 
it only as labor, is a disagreeable one. In any form, disease is unpleasant to look 
upon. The sick chamber affords no pleasant sights. The physician is made the 



iv PREFACE. 

witness both of physical pain, and moral infirmity. Struck by disease, the attrac- 
tive parts of man's nature are clouded over. He is fretful, irritable, complaining. 
His pride his humbled ; his intellect is disturbed ; his whole character, in a word, is. 
transformed. Too often, alas, is sickness the consequence of his own folly. Self- 
indulgence, the gratification of appetites, the exhausting toil of avarice, the feverish 
labors for human applause, all produce their baneful effects upon the constitution. 
But to the medical attendant, the moral aspects of these facts are not to have any 
influence upon his skill or his care. At the best human nature is but weak. This 
is the first truth for us to learn. And in whatever way this weakness is exhibited, 
the philanthropic heart will feel, that it is a pleasure as well as a duty to relieve 
bodily infirmities, whenever, and however they appear. This is the higher and 
nobler view of medical science. It devotes itself to the mitigation of pain, the abate- 
ment of disease, the restoration to health. In doing this, its minister must be the 
spectator of much that is disagreeable, but he is rewarded by the lofty satisfaction 
of feeling that although personal comfort, is sacrificed, and sympathy is often pain- 
fully excited, yet it is through such a road that benevolence has the widest scope, and 
meets with the richest return for its labors. 

In this view, all diseases are alike to the faithful physician. He makes no dis- 
tinction between the causes that have developed them. He sees man suffering, and 
all his faculties are employed to give him health. Disease he regards as a mis- 
fortune and not as a punishment. 

Of all the affections that afflict man, there is no one more terrible in its conse- 
quences than syphilis. Dreadful as it is to the person who first contracts it, frightful 
as frequently are its ravages in his constitution, ending, occasionally, in destruction, 
yet it is a disease of deeper interest, and more to be lamented, when it is transmitted 
to offspring. Children often come into the world with the disease hideously mani- 
fested to the eye. covered with blotches and sores, with wrinkled faces having the 



PREFACE. v 

appearance of old age, and it is probable, that every particle of the living organism 
is equally tainted with the poison. When such a condition exists, it cannot be 
doubted that life will too frequently be short and full of pain. Scrofula, consump- 
tion, and other diseases that are sometimes hereditary, are in many cases, its fruit ; 
and one way to stay the devastating march of those fearfully fatal affections, is, 
as far as practicable, to eradicate syphilis from the world. 

Would it not seem, that a disease so prevalent and so direful, ought to excite the 
deepest interest among medical men, both as respects its true pathology and its 
treatment ? What excuse can he offer for his deficiency, who calls himself a sur- 
geon, and yet does not even recognize the disease when he sees it, and is ignorant 
of the best means of checking it and preventing any future evil consequences 1 Is 
it enough for him to say, that to the imagination the disease is a loathsome one ; 

that it is a disreputable one to have, and a disgusting one to treat 1 Such an excuse 
may, possibly, satisfy him who has no better, but it will not satisfy science nor 
philanthropy. 

Whoever undertakes the medical profession with a true spirit, will never rest con- 
tented with knowing only a limited part of it. There is no subject that he thinks 
unworthy of investigation and study. He cannot be satisfied with a smattering 
knowledge of what he is bound to understand well. He feels resting upon him a 
double obligation — one, the duty he owes to the public to whom he announces that 
he is a qualified member of a noble profession ; the other, the duty he owes to him- 
self, to make and maintain a reputation for attainments and skill. 

There are some practitioners, indeed there are many, who are ignorant of venereal 
diseases, because, they fancy it is not respectable to treat them : of all such persons, 
it may be asserted, as beyond dispute, that their ignorance is not confined to these 
diseases alone. They will be found deficient in all other points, and are not pro- 
perly qualified for the responsibilities they have assumed. Whoever has a just 



Vi PREFACE. 

appreciation of the medical art, will not know any difference in the respectability of 
diseases. All maladies are alike fit subjects for his care and reflection ; and the 
only distinction that he acknowledges, is that which arises from their greater or less 
gravity. Circumstances may, indeed, direct his practice in a particular channel, so 
that his business will be inclined to one class of affections rather than another, but 
this is not because he regards some as beneath or unworthy of his notice. 

Quackery has profited by the neglect that venereal diseases have experienced, 
and it is notorious that pretenders have secured a large share of such practice. It 
is time for the profession to free itself from this reproach. The welfare of society 
is as deeply concerned in this, as it can possibly be with any other disease that 
afflicts the human family. 

Entertaining such opinions, I resolved to present to my medical brethren a book, 
which will, T trust, afford every facility for becoming intimately acquainted not only 
with the mode of treating this class of diseases, but for knowing their exact appear- 
ances when they occur. Such a work I believe is still wanted. Much has been 
written on these and kindred subjects, especially on the eastern side of the Atlantic, 
but no author that I have met with, furnishes all that is needed on the various affec- 
tions that properly group together in a work of this description. There are a few 
monographs, it must be admitted, that are excellent ; but a systematic work, in my 
judgment, is required, embracing all the leading principles and facts, and avoiding 
the introduction of matter that is unnecessary to the proper appreciation of the 
subject. 

This undertaking has been to me one of considerable labor. Every author of any 
pretension I have examined, and whatever I have found useful has been incorporated 
in the following pages. My aim has been to make not a theoretical, but a practical 
book. Much of the matter in the pages of those already published is obsolete ; 
much more of it should be so. To make a really instructive work on this subject, 



PKKKACK. VII 

it is necessary to delve ill the dust of medical literature, and separate the gold from 
tin- dross in which it lies concealed. This has been a part of my task. For years, 
these diseases have occupied a large share of my attention. The practice of others 
has been subjected to the experiment ui/i cruris; while my opportunities, which, it 
may be alleged, have not been restricted, have never, I hope, been permittced to 
pass without taking advantage of them for the improvement of this branch of medi- 
cal science. 

The most thorough way, unquestionably, to study disease, is on the living subject. 
For many obvious reasons, in this country, such an advantage can only be enjoyed 
by but very few. Venereal wards of large hospitals, and a constant attendance on 
the part of the student, are necessary to attain proficiency by this method. Pictorial 
representations afford a very good substitute for clinical study. In some respects, 
pictures, when executed with fidelity, possess an advantage over studies pursued in 
Institutions for the sick. The peculiarities of appearance can be examined more at 
leisure, and this may be repeated as often as necessary to understand precisely the 
distinction between one form of the disease and another. At all times, plates may 
be referred to when any doubts exist as to the real nature of the symptoms under 
observation. We may thus be said to have before us, perpetually, a guide that will 
not readily permit us to go astray. 

My object, in part, has been to furnish a work of this nature. It contains thirty- 
seven colored plates, and a large number of fine wood engravings. No expence has 
been spared in having the pictures perfect delineations of disease. 1 have intended 
to make this the most elegant and accurate medical publication that has ever been 
issued from the American press, and I do not hesitate to say, that the plates will 
bear a favorable comparison with the finest artistical productions of London or Paris. 
Some of the'drawings I have borrowed from the great work of Ricord, others from 
Acton and Judd, and some I have had copied directly from life. 



viii PREFACE. 

The execution of the illustrations in colors, was entrusted to Mr. Francis Michelin. 
a lithographic artist of this city ; and it can scarcely be necessary to add, that he pos- 
sesses both judgment and skill — his work speaks for him. 

To increase the value of the plates, each one is accompanied with a history of 
the case that furnished the subject for the artist's pencil. The reader will thus, at 
the same time, be made acquainted with the actual appearance of disease, and with 
the treatment most advisable to adopt for subduing it. 

The engravings on wood were done by Messrs. Lossing and Barrett ; and for the 
faithful manner in which they have been executed, I feel that they are entitled to this 
public acknowledgment. 

HOMER BOSTWICK, Surgeon. 

No. 504 Broadway. 



ANALYTICAL 



TABLE OF CONTENTS. 



CHAPTER I. 
ANATOMY OF THE MALE PARTS OF GENERATION. 
Parts within the Pelvis. — The Bladder.— The Sphincter of the Bladder. — The Prostate Gland. 
Muscles of the Ureters. — Structure of the Penis. — Of the Urethra. — Of the Testes. — Descent of 
the Testis. — Vessels of the Cord and Testis. — Vesiculae Seminales. p. 17. 



CHAPTER H. 
ANATOMY OF THE FEMALE PARTS OF GENERATION. 
Anatomy of the Female Pelvis. — External Parts of Generation. — The Urethra. — Parts contained 
•within the Pelvis. — The Bladder. — The Vagina; its shape, connexions, &c. — The Uterus ; its 
blood vessels. — The Ovaries, p. 45, 



VENEREAL DISEASES. 



CHAPTER HI. 
INTRODUCTORY REMARKS. 
Venereal Diseases defined- — "Why is man afflicted with them ? — They are not to be considered as 
punishments for sin. — When and where did Syphilis originate 1 — Its modern origin. — Its first ap- 
pearance in Europe. — Its frightful effects in Otaheite. — Nature of the Syphilitic Virus. — Its che- 
mical properties. — Gonorrhceal Virus. — Its action supposed formerly to be identical with that of 
Syphilis. — Syphilitic chancre and bubo. — Constitutional effects. — Secondary symptoms. — Govern- 
ment interposition necessary to extinguish these diseases, p. 54. 



CHAPTER IV. 
PRIMARY SYHPILIS. — PROPHYLACTICS. 
Tee disease can only be prevented by ihe Fublic Authorities. — What some European nations have 
done towards it. — England and the United States have done nothing. — No antidote has been dis- 
covered which can prevent its develoj ment. — General suggestions to avoid infection. — Government 



X TABLE OF CONTENTS. 

regulations to protect the public against other contagious diseases. — Neglect of this disease. — The 
medical profession should earnestly take up the subject, p. 77. 

CHAPTER V. 
PRIMARY SYPHILIS. — CHANCRE. 
Definition of chancre. — Infallible test of its syphilitic character. — Different varieties. — Remarks upon 
its diagnosis. — The time that may elapse between the infection and the appearance of the sore. — It 
may sometimes be seen on the lips or tongue. — Prognosis; this is affected by the variety. — The 
complications. — Buboes not a necessary result of chancre. — When does chancre cease to produce 
the specific virus 1 — The Abortive Treatment. — The secondary symptoms influenced by the variety 
of chancre. — Local Treatment: Excision; Caustic. — Constitutional Treatment: Mercurials; Re- 
gimen. — Circumstances modifying the Treatment. — Chancres in the Urethra ; in the Vagina; aj*d 
in the Os Uteri. — When Cantharides may be useful. — Chancres accompanied with violent inflam- 
mation, with hemorrhages, &c. p. 88. 



CHAPTER VI. 
PRIMARY SYPHILIS.— BUBO. 
Definition of Bubo. — First symptoms. — Other causes than Syphilis produce it. — Men more liable 
than women to have bubo. — Chancres about the frenum most apt to cause it. — Diagnosis of Syphi- 
litic bubo. — Treatment — the abortive: cold; compression; and antiphlogistic regimen. — Treat- 
ment in a more advanced stage : when pus has formed, the bubo must be immediately opened. — 
Treatment of the Ulcer. — Inoculation a test of its specific character. — Mercury should be employed 
for its constitutional effects. — Powerful stim ulants or caustics required in some cases. — Indurations 
following bubo. — Fistulous openings, p. 116. 



CHAPTER VII. 

SECONDARY SYPHILIS. —GENERAL DESCRIPTION. 
There is always danger of secondary symptoms after the primary disease, if mercury be not employed. 
They manifest themselves at uncertain times. — The most frequent form of secondary affections. — 
Tertiary affections. — Secondary disease cannot produce chancre. — Secondary and tertiary affec- 
tions contagious. — Some reasons for this opinion. — Prognosis of constitutional syphilis, p. 130. 



CHAPTER VIII. 
SECONDARY SYPHILIS. — GENERAL PRINCIPLES OF TREATMENT. 
Spontaneous cures may occasionally occur. — Anti-mercurial treatment. — Effects of climate ; cloth- 
ing ; diet ; bleeding. — Necessity of attending to the digestive organs. — Woody decoctions. — Qui- 
nine. — Iron. — Iodine. — Mercury. — Preparations of gold and silver. — The experience of three 
centuries in favor of mercury. — General rules for administering it. — May be administered by fric- 
tions, by fumigations, and by the mouth. — The different preparations — iodide, proto-chloride, and 
bi-chloride, the cyanide, and the deuto-phosphate of Mercury most usually employed. — The cal- 
cined Mercury. — The iodide of Potassium, p. 138. 



CHAPTER IX. 

SECONDARY SYPHILIS. — CUTANEOUS ERUPTIONS. 
The usual premonitory symptoms. — Exanthemata : treatment. — Squama : treatment.— Vesiculce 
treatment. — Pustulce — two species, the psydraceous and the phlyzaceous : treatment. — Papulce 



T UBLE OP CONTENTS. xi 

treatment. — Tubtrcula — several varieties: treatment. — Ulcerations, Vegetations, or Excrescences : 
treatment. — Condylomata or MucousTiiherelcs ; treatment, p. 150, 



CHAPTER X. 

SECONDARY SYMPTOMS.— ULCERATIONS, &c. 

Or tlie tonsils, mouth and throat. — The premonitory general symptoms. — The local. — Tonsils most 
liable to he first attacked. — The ulcer sometime-; resembles cancer. — Many varieties of ulcer. — 
General sloughing alarming. — The local treatment: mainly gargles and caustic. — The general 
treatment : the same as in the primary disease. — Iritis : symptoms. — General and local anti-phlo- 
gistic treatment: Blisters; Mercurial dressings; Belladonna. — Syphilitic Sarcocele : symptoms: 
treatment. — Falling of the hair and nails ; treatment. — General advice upon practice, p. 163. 



CHAPTER XL 
TERTIARY SYPHILIS. — GENERAL SYMPTOMS. 
Tin v are liable to be confounded with other affections. — This form loses in a great measure its spe- 
cific character. — The secondary has neai'fy always preceded the tertiary disease. — Lupus Syphi- 
liticus : general treatment — local treatment. — Pains in the hones: treatment. — Inflammation of 
the peril istium. — Bones diseased: treatment. — A prevailing error that the disease of the bones is 
caused by mercury. — Osseous tumors : treatment — Iodide of Potassium — Blisters. — Deep-seated 
Tubercles of the cellular tissue : treatment, p. 172. 



CHAPTER XII. 
SYPHILIS IN INFANTS. 
Disease inherited from a parent, contracted from a nurse, or by other infection from a person having 
secondary syphilis. — Curious case in illustration. — At the time of birth the child may manifest 
symptoms of the disease. — Sometimes the symptoms aie not noticed until several days or weeks 
afterwards. — The ordinary symptoms are copper-colored blotches on the skin; ulcers in the 
throat. — Consequences when imperfectly cured. — The disease in the infant contagious. — Treat- 
ment : Mercurials. j } - 179. 



Table showing the result of Inoculations of Syphilitic Virus, &c. p. 205. 



CHAPTER XIII. 
GONORRHOEA. 

Its definition. — Its synonyms. — Its antiquity. — May be produced by leucorrhceal discbarge. — Un- 
til lately regarded as a variety of syphilis — May be complicated with syphilis. — Difference in the 
liability of individuals to contract it. — The matter will retain its infectious character for a long pe- 
riod. — Illustrative Cases. — Varieties of the disease. — Symptoms of the disease in the male, in the 
first, second, and third stages. — Prognosis very difficult, p. 209. 

CHAPTER XIV. 
GONORRHOEA.— TREATMENT. 
Prophylaxy. — No antidotes known. — Police regulations. — Ablutions. — Abortive treatment. — 
Antiphlogistic regimen and avoidance of all excitement. — "When the disease is first established it 



x ii TABLE OF CONTENTS. 

may be checked by astringent injections. — Revulsive treatment. — General and local depletion in 
the more advanced stages. — Purgatives; Cubebs ; Balsam Copaiba; Antimonials. — Ulcers, and 
their treatment. Inflammation reaching the bladder : its treatment. — Gonorrhoea in women : treat- 
ment Some complications requiring different treatment. — Injections into the uterus. — Tampon. 

The diagnosis of gonorrhoea in the female sometimes very difficult, p. 215. 



CHAPTER XV. 
BALANITIS AND POSTHITIS. 

Their definition. — The symptoms. — The common causes : treatment — cauterization ; astringent and 
anodyne lotions; antiphlogistics. — Operation for phymosis. — Some of the consequences of Balanitis 
when improperly treated. — Gonorrhoea common to both sexes. — Of the eyes: men and infants 
most liable to it. — Caution. — Treatment : general and local antiphlogistic measures ; cauterization ; 
narcotics. — Chemosis : treatment — excision; scarification; cauterization; issues. — Gonorrhoea of 

' the mouth and nose ; of the anus : treatment, p. 221 . 



CHAPTER XVI. 
VARIOUS MEDICINES FOR GONORRHOEA. 
Balsam Copaiba : its mode of action — different methods of administration — its combinations with 
other medicines. — Cubebs — its forms and combinations. — Turpentines, p. 231. 



CHAPTER XVII. 
SYMPATHETIC BUBO, OR INFLAMMATION OF THE INGUINAL GLANDS. 

Frequent consequence of Gonorrhoea. — Not produed by specific virus. — The result of irritation in 
another part. — Treatment : general antiphlogistic and revulsive, p. 235. 



CHAPTER XVIIL 

ACUTE INFLAMMATION OF THE TESTICLE. 
The different designations by which it is known. — Symptoms. — The effects of sympathy upon different 
organs of the abdomen. — Seldom attacks both testicles at once. — Seldom suppurates when it is 
sympathetic. — Diagnosis. — May be mistaken for strangulated hernia. — The mode of distinguishing 
between them. — Causes. — Most common one, irritation of the urethra. — Objections to the view of 
Sir Astley Cooper. — It is most frequent when the inflammation has reached the prostatic portion of 
the urethra. — Injections — the effects. — Effusion of serum and coagulable lymph. — Swelling of 
the epididymis. — Wasting of the testis. — Treatment: purgatives; depletion; evaporating lotions ; 
fomentations ; poultices ; suspensory bandage ; bandaging the organ ; when abscesses form, they are 
to be early opened ; opium ; mercurials ; preparations of iodine ; stimulating plasters ; tartrate of anti- 
mony, p. 237. 



CHAPTER XIX. 
VENEREAL INFLAMMATION OF THE TESTICLE. 
A secondary symptom. — The swelling of the testicle gradual. — Generally accompanied with syph- 
ilitic sore throat, venereal eruptions, and periosteal inflammation. — The disease very rarely proceeds 
to suppuration. — Treatment : Mercury a specific for it. p. 247. 



rABLB OF CONTENTS. xiu 

CHAPTEB w 

PHYMOSIS AND PARAPHYMOSIS. 
What it is thai constitutes phymosis. — What it is that constitutes paraphymosis. — Their causes. — 
Tin' effects of phymosis. — Treatment of phymosis: the soothing method ; operation by incision j 
operation l>y circumcision. — Treatment of paraphymosis: the same general indications as in phy- 
mosis ; gentle pressure ami dexterous manipulation ; operation with the knife for the reduction. — 
Subsequent treatment. p. 219. 



CHAPTER XXI. 
GLEET. 
Its definition. — Commonly succeeds Gonorrhoea. — Its infectious character considered. — Proceeds 
from debility of the mucous membrane. — Various exciting causes. — Its treatment. — If there be 
general debility of the system, tonics and other remedies for the improvement of the general health 
are to be employed ; astringent injections — the manner in which they should be used; stimulants and 
bougies — rule for using them ; cauterization. — Glands of Cowper affected. — Treatment : bougies 
and blisters ; cauterization; counter-irritation. — Scrofula an occasional cause. — Treatment. — Stric- 
ture sometimes a cause. — Treatment. — Diseased prostate a cause. — Treatment, p. 253. 



CHAPTER XXII. 
STRICTURE OF THE URETHRA. 
Definition of stricture. — Its causes. — Dimensions of the urethra. — Varieties of stricture. — Their 
symptoms. — The opinions of Hunter and Home controverted. — The seat of stricture. — Reten- 
tion of urine. — Some of the consequences of stricture. — Diagnosis. — Mode of introducing catheters. 
p. 263. 

CHAPTER XXni. 
STRICTURE. — TREATMENT. 
The use of the catheter and bougie. — Surgical operations for retention of urine. — Treatment for radi- 
cal cure. — Internal remedies. — Dilitation by instruments. — The varieties of instruments. — False 
passages. — Hemorrhage : its treatment. — Constitutional symptoms consequent upon the use of the 
bougie. — Cauterization to remove the stricture not advisable. — Incision in ceitain cases the only 
proper treatment, p. 279. 



CHAPTER XXIV. 

STRICTURE. — CASES ILLUSTRATING ITS TREATMENT. 
Case I. p. 299. 



CHAPTER XXV. 
FALSE PASSAGES. 
Definition. — The usual causes of them. — Where they are most commonly situated. — A peculiar 
condition of the mucous membrane may favor the accident. — Certain instruments more liable than 
others to cause them. — The operator often in fault. — The proper way to pass the instrument. — 
Difficulty of knowing when a false passage exists. — Necessity for caution. — The porte-empreinte for 
taking a cast of the part. — Further directions for proceeding. — No certain sign for distinguishing a 
false passage — pain, hemorrhage. — Experience useful. — The treatment : catheter sometimes ne- 
cessary. — Puncture of the bladder, p. 313. 



XIV 



TABLE OF CONTENTS. 



CHAPTER XXVI. 
INFILTRATION OF URINE, ABSCESS AND FISTULA. 
Generally the consequences of gonorrhoea and stricture. — The immediate causes of infiltration : stric- 
ture ; ramollissement ; rupture of the urethra. — Symptoms : swelling in the perinaeum, scrotum 
or penis ; intense pain ; inflammation ; rigors; fever; great debility ; pulse intermitting ; hiccough; 

delirium ; death. Gangrene — its treatment : incision; the constitution to be supported by tonics. — 

Fistula* succeed. — Diagnosis. — Treatment: by dilating the stricture when it exists; the use of 
caustic. — Blind fistulae to be opened with the lancet, p. 318. 



CHAPTER XXVII. 
HYDROCELE. 

Hydrocele of the Tunica Vaginalis. — Its definition. — Causes. — Symptoms. — Diagnosis. — Scirrhous 
testicle. — Treatment: divided into palliative and radical; tapping with trocar ; needles; injections 
into the cavity — the different kinds of injections — effects. — Accidents that may result from care- 
lessness. — Treatment by electro-galvanism, p. 324. 

Congenital Hydrocele. — Its causes. — Symptoms. — Diagnosis. — Treatment: if a hernia be compli- 
cated with it, it must first be reduced ; methodical compression upon the ring, with topical applica- 
tions ; tapping ; injections objectionable, p. 330. 

Hydrocele of the Cord. — Causes. — Infiltration, and an accumulation of water in cysts. — Symptoms 
of hydrocele from infiltration. — Treatment : if moderate it is best to do nothing. — If inflammation 
be threatened, the operation by incision only will be effectual, p. 331. 

Encysted Hydrocele. — Causes. — May be mistaken for a supernumerary testicle. — Treatment, p. 332. 



CHAPTER XXVIII. 

CIRCOCELE AND VARICOCELE. 
Description of Circocele. — Symptoms. — Causes. — It may be mistaken for omental hernia. — Its 
diagnosis. — Treatment : local bleeding and lotions ; tying spermatic artery ; castration. — Varicocele. 
It resembles circocele. — Produced by the same causes. — Cooper's operation for its relief, p. 333. 



CHAPTER XXIX. 

DISEASE OF THE PROSTATE GLAND. 
The prostate gland, where situated. — Its diseases. — Their causes. — Symptoms. — The gland, if en- 
larged, may be felt by introducing the finger in the rectum. — Treatment, p. 336. 



TABLE OF COLORED PLATES. 



PLATE I. — (Frontispiece.) — Tuberculous syphilis : iritis: secondary symptoms. Case. 
PLATE II. — Primary ulcers beginning with pustules : regular inoculation, p. 74. 
PLATE III. — Primary follicular ulcer : virulent bubo : regular inoculation, p. 82. 
PLATE IV. — Primary ulcers : acute balano-posthitis : phymosis : gangrene, p. 85. 



p. 168. 



TABLE OF CONTENTS. xv 

PLATE V. Fig. 1. — Primary ulcers of the meatus urinarius and prepuce : inflammation of a lym- 
phatic vessel: bubo, followed by ulceration and accidental inoculation, p. 93. 

Fig, 2. Blenorrhagia : primary ulcer of the meatus urinarius : suppurated lymphatic vessel and 

lmho : artificial inoculation, with the result, p. 95. 
PLATE 71. — Primary ulcer on the neck of the uterus, p. 103. 
PLATE 711. — Primary ulcers : early secondary symptoms, p. 110. 
PLATE VIII. — Fig. 1. — Non-indurated primary ulceration of tho upper gum. p. 112. 

Figs. 2, 3. — Non-indurated primary ulceration of the frenum, (perforating chancre) : paraphymosis. 

p. 113. 
Fig. 4. — Indurated gangrenous chancre : vesiculo-pustulous eruption : early secondary accidents. 
, " P . LIS. 
PLATE IX. — Diptheritic primary ulcer, with a non-indurated base : balano-posthitis, with erosion : 

syphilitic roseola. p. 121. 
PLATE X. — Polymorphous tuberculous syphilis: accident of transition, p. 127. 
PLATE XL — Pustulo-crustaceous syphilis : secondary symptoms, p. 136. 
PLATE XII. — Syphilitic Crustacea. (Variety of convex rupia.) p. 146. 
PLATE XII, BIS. — Polymorphous vegetations, p. 154. 

PLATE XIII. — Fig. 1. — Impetigenous tuberculo-crustacea : relapse of secondary symptoms : slow 
form. p. 159. 
Fig. 2. — Ulcerated impetigenous syphilis. (Variety of impetigo rodens.) p. 161. 
PLATE XIV. — Rupia prominens. p. 193. 
PLATE XV. — Exanthema roseolum. p. 1S5. 
PLATE XVI. — Exanthema puniceum. p. 185. 
PLATE XVII. — Puniceous patches with papulae, p. 187. 
PLATE XVIII.— Papuhe elongatee. p. 187. 
PLATE XIX. — Lichen venereus. p. 1S9. 

PLATE XX. — Lichen circumscriptus, vesicles, maculae, and ultimately, lichen solitarius. p. 189. 
PLATE XXL — Large Vesicular lichen, p. 191. 
PLATE XXII. — Herpes venereus. p. 191. 
PLATE XXIII. — Herpes circinatus. p. 193. 
PLATE XXIV. — Ecthyma venereum, p. 195. 
PLATE XXV. — Ecthyma venereum : clustered lichen, p. 195. 
PLATE XXVI. — Large Ecthyma, p. 197. 
PLATE XXVIL— Spili coccinei. p. 198. 
PLATE XXVIII. — Spili cruentati. p. 199. 
PLAT E XXIX. — Spili cuprei. p. 199. 
PLATE XXX. — Phymatosis ovata. p. 201. 
PLATE XXXI. — Phymatosis annulata. p. 202. 
PLATE XXXII. — Lepra venerea*, p. 203. 
PLATE XXXIII. — Psoriasis venereae. p. 203. 
PLATE XXXIV. — Fig. 1. — Excoriations of the os uteri, p. 208. 
Fig. 2. — Granular condition of the os uteri, p. 208. 



xvi TABLE OF CONTENTS. . 

PLATE XXXV. — Fig. 1. — Ulcerations of the cervix uteri, p. 214. 

Fig. 2. — Catarrh of the uterus, p. 214. 
PLATE XXXVI. — Fig. 1. — Balanitis. Fig. 2. — Vegetations. Fig. 3. — Eczema. Fig. 4. 
Herpes preputialis. p. 226. 



TABLE OF WOOD ENGRAVINGS. 



PLATE I. — Showing the pelvis divided on the meridian line, and the right side of the genital organs 

of the male. p. 18. , 
PLATE II. — Showing the bladder and urethra laid open in its whole length, p. 28. 
PLATE III. — Shows the spermatic cord and its relations, p. 37. 
PLATE IV. — Figs. 1, 2. — Injected human testes, &c. p. 40. 
PLATE IV. — Human spermatozoa, p. 42. 

PLATE V. — External genital organs of an unmarried female, p. 46. 
PLATE VI. — External organs of the unmarried female with the labia separated, p. 47. 
PLATE VII. — A side view showing a portion of the internal female organs of generation, p. 50. 
PLATE VIII. — The uterus, fallopian tubes, the ovaria, and a part of the vagina of a young female 

exposed, p. 57. 
PLATE IX. — Truss for compressing buboes, p. 118. 
PLATE X. — Inguinal bandage, p. 126. 
PLATE XI. — Tri-valve speculum — the best in use. p. 223. 
PLATE XII. — Speculum chair, p. 224. 
PLATE XIII. — Compression of the testicle, p. 245. 
PLATE XIV. — Phymosis. p. 249. 
PLATE XV. — Paraphymosis. p. 250. 
PLATE XVI. — Operation for phymosis. p. 251. 
PLATE XVII.— Cast of a urethra, p. 264. 
PLATE XVIII. — Represents the formation of stricture in the urethra, and the bougie doubled 

upon itself when improperly used. p. 267. 
PLATE XIX. — Shows porte-empreinte for taking an impression of strictures in the urethra, p. 268. 
PLATE XX. — Shows strictures, and the impressions taken of them with the porte-empreinte. p. 269. 
PLATE XXI. — Shows curved bougies and catheters of full size. p. 276. 
PLATE XXII. — Shows mode of puncturing the bladder, p. 281. 
PLATE XXIII. — Shows conical and fusiform bougies, p. 288. 
PLATE XXIV. — Shows cauterizing instrument and bougies, p. 289. 

PLATE XXV. — Shows the mode of cauterizing the prostatic portion of the urethra, p. 290. 
PLATE XXVI. — Shows Ricord's and Lallemand's porte-caustiques. p. 295. 
PLATE XXVII. — Shows hoth Ricord's scarificator and the one I prefer, p. 297. 
PLATE XXVITI. — Shows the mode of retaining a bougie in the urethra, p. 298. 
PLATE XXIX. — Shows the mode of operating for hydrocele, p. 327. 
PLATE XXX. — Shows some of the dangers in operating for hydrocele, p. 329. 
PLATE XXXI. — Shows the operation for tying the spermatic vessels, p. 334. 
PLATE XXXII. — Shows an enlarged prostate gland, p. 337. 
PLATE XXXIII. — Shows the douche-bath. p. 340. 



ANATOMY 



OF 



THE ORGANS OF GENERATION. 



Ln examining diseases, a difficulty is often experienced, by those who are not 
familiar with Anatomy, in understanding the descriptions involving the relations and 
structure of organs. Anatomy and Physiology is necessarily the basis of sound 
medical knowledge ; and every one must have felt how greatly labor is abridged, 
and how much more precise are our ideas of the pathological state, when we are 
acquainted with the situation, organization, and function of the parts we are study- 
ing. To make this work complete in itself, contrary to the practice which generally 
prevails, I have determined to introduce the subjects treated of, by presenting an 
Anatomico-Physiological account of the Genito-Urinary apparatus. 



CHAPTER I. 

ANATOMY OF THE MALE PARTS OF GENERATION. 

Parts within the Pelvis. — The bladder of Urine. — The Sphincter of the Bladder. — The Prostate 
Gland. — Muscles of the Ureters. — Structure of the Penis. — Of the Urethra. — Of the Testes. — 
Descent of the Testicle. — The Vessels of the Cord and Testicle. — Structure of the Testicle. — The 
Vesiculae Seminales. 

As there is no very accurate division betwixt the viscera of the abdomen and 
those of the pelvis ; as the uterus and bladder, being viscera of the pelvis, rise into 
the belly when distended, and are, in every respect, like the abdominal viscera, many 
have altogether objected to a division of the viscera of the abdomen and pelvis : 
nevertheless, there appears to be good reason for this division of the subject. The 
functions of the parts are different; the manner of their connexion is different, and 
their diseases have widely different effects. 
8 



18 



ANATOMY OF THE MALE PARTS 



The pelvis consists of the sacrum, os coccygis, and ossa innominata, and anato- 
mists have distinguished the true and the false pelvis. The false pelvis is formed 
of the extended wings of the ossa ilii, and supports the viscera of the abdomen. 
The true pelvis consists of that cavity which is beneath the promontory of the 
sacrum and the linea innominata ; it contains, in man, the rectum, the urinary blad- 
der, the prostate gland, the vesiculse seminales, and part of the urethra. In woman 
it contains the rectum, vagina, uterus, Fallopian tubes, ligaments of the uterus, and 



ovana. 




EXPLANATION OF PLATE. 

The pelvis is divided on the meridian line, and the engraving shows the right side of the organs. 

1. The vertebral column. 2. Colon. 3. Bladder. 4. Ureter, conducting the urine from the kidney 
to the bladder. 5, 6. Vasa deferentiae. 7, 8. Vesiculae seminales. 9. Prostate gland. 10. One of 
the glands of Cowper. 11. Canal of the urethra. 12. Bulb of the urethra. 13. Grlans penis. 14. Right 
testicle. 15. Skin covering the penis. 16. Prepuce. 17. The Figenum. 18. Corpus Cavernosum. 
19. Pubis. 



\ 



OF GENERATION. L9 

THE BLADDER OF UKINE. 

The Madder of urine must be classed with the membranous or hollow viscera. It 
is a bag or receptacle into which the urine slowly distils through the ureters, that it 
may be expelled at convenient seasons. It is nearly of a regular oval form, when 
moderately distended, the ends being obtuse ; but from its connexions, and the pres- 
sure of snrronnding parts, this regular extension is not allowed in the living body. 
When seen moderately distended, in situ, it rises somewhat pyramidal upwards ; it 
is flat upon the os pubis on the fore part, and towards the back and lower part a por- 
tion may be seen somewhat sacculated, and below the level of the commencement of 
the urethra. 

We describe the body, fundus, neck, and lateral parts. The fundus is the upper 
part ; the neck is where the urethra commences, and where the prostate gland is 
attached ; the lateral part is, where being distended it stretches at its lower part to 
the sides of the pelvis. 

On the fundus there is a ligamentous process, continued in a direction towards 
the umbilicus ; this is the urachus. I would not give the name here, which is pro- 
perly applicable to a tube peculiar to the foetus of quadrupeds, was it not to add that 

sometimes, even in the adult human subject, there is an open tube, so that the urine 
passes out from the umbilicus.* 

The bladder is situated higher in the boy than it is in the adult. In the foetus 
it is almost entirely out of the pelvis, and reaches nearly to the umbilicus. At three 
years it is said to rise no more than three fingers' breadth above the os pubis ; at 
twelve it is only half an inch above the level of the bone ; at eighteen it is said to be 
completely hidden behind the pubes. 

When the bladder is empty, or contains only a moderate quantity of urine, it takes 
a triangular figure in the dead body, the base of which rests on the rectum, and the 
apex is attached to the back of the os pubis ; and when in dissection you look down 
into the pelvis, you find the back part of the bladder flat, and as it were stretched 
obliquely upon the os pubis. 

* Fernelius de part. mmrb. et symptom, gives an example of a man who, having an obstruction at the 
neck of the bladder, passed his mine by the umbilicus. Wepfer gives a similar case of a man with 
calculus. These are quoted by Albinus, Annot. Acad, and also the Philos. Transactions, n. 323. See 
also Sandifbrt The.e. vol. iii. p. 234 — 246. Haller. Elemen. Physiol, lib. xxvi. § ii. 



20 THE BLADDER OF URINE. 

Structure of the Bladder. — Like the other hollow viscera, the bladder con- 
sists of several coats. 

The Peritoneal Coat of the bladder does not surround the bladder, but only 
covers the fundus and back part. It is like, in every respect, to the peritoneal coat 
of the abdominal viscera ; smooth without ; and adhering to the inner coat by cel- 
lular membrane ; which cellular membrane is, however, of a looser texture, and in 
greater quantity than under the peritoneal coat of the .abdominal viscera. This 
peritoneal coat is, no doubt, of much service, as a division in obstructing the course 
of inflammation arising from the diseases in the lower part of the pelvis, or from 
operations performed on the bladder, rectum, or perinseum. Were it not for the 
loose peritoneum spreading over the cellular texture of the pelvis, we could neither 
be so bold nor so successful in our operations here. That portion of peritoneum 
which covers the back part of the bladder, forms a particular transverse fold when 
the bladder is contracted. This fold surrounds the posterior half of the bladder, 
and its two extremities are stretched towards the side of the pelvis, so as to form a 
kind of lateral ligament. 

Though in the contracted or moderately distended state of the bladder, the peri- 
toneum stretches from the back of the os pubis to the bladder, the distension of the 
bladder, in an immoderate degree, raises the peritoneum off from the pubes, so that 
the bladder can be struck with a trochar, or lithotomy performed above the pubes, 
by an incision directly into the bladder, without piercing the outer or peritoneal coat. 

Towards the lower part, the bladder, as we have seen, is invested only by cellular 
membrane, which takes the place of the peritoneal coat of the fundus. This tissue 
is very loose, and permits the distention and contraction of the bladder, which loose- 
ness of texture is a matter of regret, when blood or urine is forced into this tissue. 

Muscular Coat. — The muscular coat of the bladder is veiy strong. Three strata 
of fibres are described by authors. They are so strong as to have been classed 
with the distinct muscles, and the whole coat has been called detrusor urinje. 
Towards the lower part of the bladder the fibres are particularly strong, and formed 
into fasciculi, and are like a net of muscles inclosing the bladder.* These fasciculi 
acquire greater thickness and strength when the bladder is excited by opposition, as 
from stricture in the urethra. 

* Morgagni Advesar. Anal:, iii. Animad. xxxix. 



I'lli: SPHINCTEH OF THK BLADDER 21 

Towards the tore and lower pari of the bladder, the muscular fibres Congregate 

into a sort of tendon, which goes off to the back <>t" the os pubis, which we count to 
be the insertion of the tendon of the bladder, and certainly this hold, which the blad- 
der lias upon the os pubis, causes it. in its contraction, to he drawn to the hack of 
the pubes. 

\\ e have an idea of the wonderful degree of contraction in the bladder, and indeed 
the extent ol* motion in the nmsenlar fibres' in general, when we consider that the 
bladder extends so as to contain two pounds of urine, and contracts so as to force 
out the last drop from its cavity. When, however, the fibres are stretched loo far, 
they lose the power of contraction, and often the young surgeon is deceived by 
what he conceives to be an incontinence of urine, while it is really an obstruction. 

THE SPHINCTER OF THE BLADDER. 

If we consider the double office of the urethra, and suppose that the seminal ves- 
sels and the ducts of the prostate gland open into the canal at a part posterior to the 
muscles which close the orifice of the bladder, we must, be also forced to admit that 
there is some imperfection in the mechanism of these parts. For in that case, the 
fluids passing from those ducts would fall back into the bladder, and the orifices of 
the ducts would be exposed to the urine in the bladder, even when the bladder was 
closed. If this were really the case, it would be inconceivable how the contents of 
the vesiculfp seminalcs could be discharged forwards, or how the urine could be 
retained while the seminal discharge was made. 

By such a train of reasoning, I was led to look for the proper sphincter of the 
bladder behind the prostate. The importance of the knowledge of the complex ap- 
paratus of muscles about the neck of the bladder, to the comprehension of the 
various causes of obstructed urine, led me to review this part of the anatomy. 

To exhibit the sphincter of the bladder, cut off all the appendages but the prostate 
gland : then make an incision into the fundus of the bladder and invert it. Begin 
the dissection by taking off the inner membrane of the bladder from around the 
orifice, or commencement of the urethra. 

A set of fibres will be discovered on the lower half of the orifice, which being care- 
fully dissected will be found to rise in a semi-circular form around the urethra. 
These fibres make a baud of about half an inch in breadth, particularly strong on 



'>■> THE PROSTATE GLAND. 

the lower part of the opening, and having mounted a little above the orifice on each 
side, they disperse a portion of their fibres in the substance of the bladder. A 
smaller and somewhat weaker set of fibres will be seen to complete their course, 
surrounding the orifice of the upper part : to these sphincter fibres a bridle is joined 
which comes from the union of the muscles of the ureters. 

Here, then, we have the muscle which closes the internal extremity of the urethra, 
the most posterior of all those muscles which embrace the urethra. It resembles 
the sphincters of the other hollow viscera ; for example, those fibres which encircle 
the pyloric orifice of the stomach. 

Third Coat. — This third coat of the bladder anatomists have called the nervous 
and cellular coat ; it consists of very extensile white lamella? of cellular membrane. 
It gives distribution to a few vessels, and connects the muscular fibres and inner 
coat. 

The Internal Coat of the bladder is very smooth on its general surface, and is 
bedewed with a sheathing mucus. When the bladder is distended, no inequalities 
are to be observed ; but when contracted, it falls into folds and rugse. From an 
acrid state of the urine, from strangury, from calculus, the mucous discharge is 
increased, even so as to form a great proportion of the fluid evacuated from the 
bladder. No visible source of this mucus is to be observed on the inner surface of 
this membrane ;* so that, probably, it is a general discharge from the surface. In- 
deed, it appears, that no follicles or cryptae, discharging at particular points of the 
surface, could have the effect of* bedewing and defending the whole surface from the 
acrimony of the urine. f 

THE PROSTATE GLAND. 

On the neck of the bladder, and surrounding an inch of the beginning of the 
urethra, there is a gland nearly of the size and figure of a chesnut. This body is 
called the prostate gland. In all anatomy, there is not a more important subject for 
the attention of the surgeon than this ; he must consider the size, relation and con- 
nexion, and diseases of the prostate gland. 

* Winslow, however, describes the glands, and Hester and Haller describe follicles, near the neck of 
the bladder, and round the insertion of the ureters. 

t When the mucous secretion is diminished by a disease of the inner membrane of the bladder, the 
calculous concretion more readily forms on the surface 



THE PROSTATE GLAND. 88 

This l)od\ is round ai the base which is towards the bladder, pyramidal forward. 

It has a lateral division, forming it into two lobes : and the older anatomists speak 

of it as double. Mr. Hunter and Sir Everard Home have excited our attention to 

the posterior or third lobe of this gland, and have drawn the most important practical 
remarks from the observation of this part of the anatomy. While the prostate gland 
surrounds the beginning of the urethra, it rests on the rectum, and it is tied by a 
fascia or ligamenl to the hack part of the os pubis. The urethra passes through it; 
not m the middle, but towards it upper surface ; so that the gland is more prominent 
downward, and is distinctly felt by the point of the finger in ano. When the cathe- 
ter is introduced, and the surgeon examines the state of parts by the rectum, he will 
first distinguish the curve of the staff, covered with the bulb of the urethra: behind 
this the catheter will feel more bare of parts, but still covered with a greater thick- 
ness of parts than one should expect from the description of the membranous part 
of the urethra. And behind this, again, he will feel the prominence of the prostate 
gland, not round, distinct, and accurately defined, but gradually lost both before and 
behind, among the surrounding cellular membrane and muscular fibres which 
involve it. 

The texture of the gland is a compact spongy substance, and when cut has con- 
siderable resemblance to a scirrhous gland. From each lobe ther.e are small folli- 
cles opening into the urethra, and from these ducts may be injected.* 

It has been said, that there is really no division of this gland into lobes ; but per- 
haps the best authority on this question is the morbid appearance. Now it happens 
sometimes, that only one side of the gland is enlarged, which is a proof that there 
is some division betwixt the lobes. This unequal swelling of the gland distorts the 
urethra, and gives it a direction very difficult to be followed by the catheter. In 
general, when equally swelled, the greater part of the gland being beneath the 
urethra, the urethra is raised up, so that the point of the catheter must be raised 
over the enlarged gland before we can pass it into the bladder. 

On the lower part of the gland, and betwixt the bladder and the vesiculae semi- 
nales, the third portion of the gland is situated, of which Morgagni gives this ac- 
count. But if any addition is to be given, says he, to the description of the prostate 
gland, it is that roundish and smooth body like a gland which often our very dili- 
gent dissector has shown in the public dissections. It lies prominent betwixt the 

* A« first ootip by Monro. 



24 THE NECK OF THE BLADDER. 

bladder and seminal capsules where they are united. Upon our most accurate 
examination, we find this to be nothing more than a part of the prostate itself.* 
After this I can see no objection to calling this part of the prostate gland Lobus 
Moegagni. Morgagni likewise observes that it is not always to be found. 

The prostate gland secretes a ropy mucus. It is probable that this mucus serves 
to sheath the passages and preserve them from the acid urine. It certainly unites 
also to the seminal fluid, and is discharged with it. 

The diseases of this gland form a subject too important and extended to be even 
hinted at here. 

Anterior to the prostate gland, and also close to the urethra, are seated the glaxVds 
of Cowper. This gland is also for the purpose of discharging mucus into the 
urinary passage. It is seated in that angle formed by the abrupt termination of the 
bulb of the spongy body of the urethra, and consequently close to the membranous 
part of the canal. It has a long duct, which, running forward an inch in length, 
terminates in the surface of the urethra. To comprehend the anatomy of the male 
urethra, we must first notice the structure of the penis. 



THE NECK OF THE BLADDER. 

On dissecting up the inner coat of the bladder, there are seen two strong fleshy 
columns, which descend from the orifice of the ureters towards the orifice of the 
bladder : they unite and run towards the prostate gland. On the surface, towards 
the cavity of the bladder, they are denser by the union of the inner coat of the blad- 
der, but they are fibrous, and this fibrous structure is made manifest by dissection 
from below. They are larger and firmer, but of the same color and structure with 
the fleshy columns of the Detrusor Urince. The variety which we find in their 
length according with the degree of contraction of the bladder, proves their muscu- 
larity. Whatever excites the action of the bladder increases the size of these mus- 
cles in a remarkable degree, and they always acquire a great increase of power and 
size when the muscular coat of the bladder becomes more distinct and powerful. 
In some of my specimens of diseased bladder, I find the cause of this to be stone in 
the bladder ; in others, an ulcer ; in many, stricture ; but always irritation and the 

* Vide Morgagni Adversaria Anatomica, Animadversio XV, prostata propago. 



THE NECK OF THE BLADDER. 25 

necessity of continual action of the bladder arc attended with an enlargement of the 

muscles of the ureters. 

When contracted, the course of these columns is distinguishable all the way from 
the mouths of the ureters to the beginning of the urethra ; and there, at their union, 
they heave up the inner coat of the bladder, producing the appearance of a tubercle 
at the lower part of the orifice of the bladder.* 

It is still the form of the inner coat which makes these fleshy columns appear to 
terminate forward in the caput gallinaceum : which they do not ; they only take a 
firmer insertion. Where these columns unite, they are most fleshy, and their fibres 
are more intricate ; then, directing their course towards the lower and backmost part 
of the prostate, they degenerate into tendon, and are inserted into the portion called 
the third lobe of the prostate. 

Although I have described the course of these muscles as proceeding from the 
back part forward, because it better corresponds with the first view we have of them, 
yet, I believe, it is more correct to consider their connexion with the prostate gland 
as the fixed point, and their connexion with the extremities of the ureters as their 
insertion. 

Use. — The use of these muscles is, to assist in the contraction of the bladder, 
and, at the same time, to close and support the mouths of the ureters. The surface 
of the bladder, where it covers their union on the inside, is endowed with an exquisite 
sensibility, which is a provision of nature for their ready and instantaneous action on 
the stimulus to pass the urine. It is here that is seated that sensibility which pro- 
duces the natural call to pass urine, and here also is the seat of diseased irritations. 

It will be observed, that the orifices of the ureters are not closed by the contrac- 
tion of the muscular fibres around them. They are defended against the return of 
the urine, by the obliquity of their passage through the coats of the bladder. It is 
well known that the extremity of the ureter enters through the coats of the blad- 
der obliquely, and that in consequence of this, there is a valvular action in the coats 
of the bladder which prevents the regurgitation of the urine into the ducts of the 
kidney. 

* It is this appearance, presented by the muscles in a state of contraction, which has led so many of 
our best authorities to confound it with the disease of the third lobe of the prostate gland. 

4 



26 STRUCTURE OF THE PENIS. 

THE PENIS, URETHRA, AND TESTES. 

STRUCTURE OF THE PENIS. 

The penis consists of a spongy substance, admitting venous blood, and supported 
by a very firm elastic covering which restrains the over distention, and gives the 
form. There are properly three spongy bodies. Two of these bodies are called 
the corpora cavernosa penis, they form the body of the penis ; the other is the 
corpus spongiosum urethra, a vesicular and spongy substance, which surrounds 
the whole length of the urethra, and expands into the bulb of the urethra in the peri- 
neum, and into the glans on the point of the penis. 

Corpora Cavernosa. — The body of the penis consists of two tubes, formed of 
a very strong sheath. This sheath has a great degree of elasticity, but at its utmost 
extension, powerfully resists the farther distention with blood. These tubes are 
united in the greater part of the length of the penis, or rather they are parted only 
by an imperfect partition. Within them is a curious tissue which forms a cellular 
texture ; into this texture the arteries pour their blood so as to occasion erection. 
The posterior extremities of these cavernous tubes are called crura penis : they 
separate in the perineum, and each of them takes hold on the ramus of the os pubis. 
Forward, these cavernous bodies, or tubes, terminate in rounded points under the 
glans penis. 

This internal tissue consists of cells connected with each other, and having a free 
communication through the whole extent of the penis. They are interposed betwixt 
the extremities of the arteries and veins, or probably while the arteries have commu- 
nication, and open into the extremities of the veins, in the common way ; they have 
such connexions with this cellular structure, that in accelerated or excited action they 
pour their blood into them ; yet in such a manner, that the blood circulates in the 
penis during erection as at other times, and the blood in the cavernous body is not 
stagnant. 

Corpus Spongiosum Urethra. — Attached to the cavernous body of the penis 
there is a spongy body similar in structure ; through this cellular or cavernous tex- 
ture the canal for the urine, called urethra, takes its course, which gives rise to the 
name spongy body of the urethra, or corpus spongiosum urethra. 



STRUCTURE OF THE PENIS. 21 

The spongy body extends the whole length of the penis ; and when; it extend* 

backwards into the perinmuo, betwixt the crura, of the penis, it is enlarged into a 
round head, which is called the bulbous part ; it is upon this, and on about an inch 
and a halt' of the lower part of the spongy body, that the ejaculator seininis or accel- 
erator urines acts ; and, as within this enlargement of the spongy body which sur- 
rounds the urethra, there is a dilation of the tube of the urethra itself, the use of the 
muscle is evident. It contracts upon this sinus of the urethra when distended with 
the discharge of the vesicals, the prostrate gland, and testicle. 

Forward, at the extremity of the penis, the spongy body is enlarged into the glans; 
thus forming the bulbous head of the penis which crowns the conical extremities of 
the cavernous body. 

The spongy substance which we have described, admitting the blood freely into 
its cells, suffers erection at the same time with the body of the penis ; and as the 
blood of the glans has free connexion with the blood of the bulb seated in the 
urethra, we may perceive that the action of the ejaculator seminis upon the back 
part of the spongy body must affect the whole extent of that body and the glans 
also. The excitement of the glans gives the action to the accelerator or ejaculator 
muscle ; the action of this muscle compresses the bulb, and in consequence, the 
whole spongy body to the extremity of the glans is made turgid, and thereby dimin- 
ishes the diameter of the urethra, adapting it to the emission of semen. Sir Everard 
Home, I observe, supposes " that an action takes place in the membrane of the 
urethra, to reduce the size of the canal, and fit it for throwing out the semen with 
the necessary velocity." I imagine the action of the accelerator, and the state of 
distention of the spongy body, resulting from it, will have this effect. 

The obtuse glans spread upon the extremities of the cavernous bodies of the 
penis, has no communication with them. We observe a posterior circular margin 
on the glans ; this is the corona glandis, and behind this there is a depression called 
the cervis. About the corona and cervix there are many little glandular bodies.* 

The Pileputium is a loose prolongation of the integuments of the penis, which 
hangs over and defends the delicate and sensitive surface of the glans. Its inner 
surface is continued from the common integuments ; this is again reflected over the 
glans. Upon the lower side and just behind the opening of the urethra, the prsepu- 

• Glandulae odoriferae of Tyson. See Morgagni Adversar. IV. Animad. XII. et sequent de tuber- 
cutis Corona penis. 



28 THE URETHRA. 



tium is tied in a particular manner to the surface of the glans. This connexion 
limits the motion of the prwputium, and is called frjsnum prjsputii. 

The whole integuments of the penis are of the same cellular structure with those 
of the rest of the body ; they are particularly loose and distensible, and unincumbered 
with fat. We may see them in emphysema and in oedema, monstrously distended. 




20 21 

EXPLANATION OF PLATE. 

Showing the Bladder and Urethra laid open in its whole length. 

1. The bladder, with the anterior face removed. 2. The ureters. 3. Their entrance into the bladder. 
4. Neck of the bladder. 5. The superior fundus of the bladder. 6. The bas-fond of the bladder. 
7. Smooth centre of the vesicle triangle. 8. Verumontanum, or caput gallinaginis. 9. Orifice of the 
ductus ejaculatorius. 10. Depression near the verumontanum. 11. Ducts from the prostate gland. 
12, 13. Lateral lobes of the prostate gland. 14. Prostatic portion of the urethra. 15. Membranous 
portion of the urethra. 16. One of Cowper's glands. 17. Orifice of excretory ducts. 18. Section of 
the bulb of the urethra, with erectile tissue. 19. Cut edges of the corpora cayernosa. 20. Cut edges 
of the glans penis. 21. Prepuce dissected off. 22. Internal surface of the urethra laid open. 
23. Outer surface of corpora cavernosa. 24, 25. Accelerator urinae muscle. 26, 27. The erector 
penis muscle. 28, 29. The vasa deferentise. 



THE URETHWA 2U 



THE URETHRA. 

The urethra is the canal for emptying the bladder. It extends from the neek of 
the bladder to the extremity of the penis. It is formed of the continuation of the 
inner and third coat of the bladder, which last forms a reticular membrane, uniting 
the inner membrane to the spongy body. It is, however, supported through all its 
length, near the bladder, by passing through the prostate gland and sphincter fibres ; 
further forward than this, where it passes from the prostate to the beginning of the 
spongy body of the urethra, it is invested and supported by firm ligamentous mem- 
branes and muscles ; and in all the length of the penis it is included in the spongy 
body, which extends from the bulb to the glans. It cannot be described as a cylin- 
drical canal, for it is closed unless distended with urine, and admits of very unequal 
distension. It begins large at the neck of the bladder ; where, immersed in the 
prostate gland, it forms a little sinus ; it is contracted again in a remarkable degree 
behind the bulb : it dilates into the sinus of the urethra, within the bulbous 
enlargement of the spongy body ; it is gradually diminished forward ; and it may be 
considered as cylindrical, or equal in its diameter from this part forward to the point 
of the glans, where it is much contracted. There is still another sinus or dilatation 
of the canal described, the fossa navicularis, where the urethra is surrounded by 
the glans.* 

The canal of the urethra is bedewed with mucus. The sources of this mucus 
are here particularly apparent ; bristles to the amount of seventy, may be admitted 
in the mouths of the little ducts. Besides the general surface and the glands which 
I have described, there are large lacunae observable ; into which mucus is secreted, 
and from which, as from receptacles, it is pressed out as the urine flows.f The 
inner membrane of the urethra is veiy delicate, and, when torn by the catheter, or by 
violent chordee, or opened by the caustic, bleeds profusely. 

* Haller Com. lib. xxvii. sect. 1, § xxx. Sir E. Home on Stiictures. Observ. de partibus genitali- 
bus sexus potioris Sandif. Thes. VIII. p. 71. 

+ These are the Canalicula Morgagni, Advers. Anat. — De glandulis urethras vide Morgagni 
Adversar. IV. An. vii. et sequent. There is much controversy and much confusion regarding the glands 
of the urethra, viz., Prostata minor es ; glandula Cowperiana ; glandulce Littreana, Sfc. The reason 
of which I believe to be that the lacuna do not appear glandular unless when they have suffered by 
inflammation ; there is no round smooth body attached to them, unless their secretions have been 
increased, and the cellular membrane and vessels are condensed around the lacunae. 



M) THE URETHRA. 

The internal membranes of the bladder and urethra, are particularly sensible ; 
drawing after them, when excited, not only the action of all the muscles in the lower 
part of the pelvis, but having sympathies in a particular manner with the testicle, 
stomach, and bowels, and with the whole system. The more curious and impor- 
tant effect of the injury of the urethra, is the paroxysm of fever which it induces. 
Observing the regular occurrence of an intermitting fever in cases of fistula in the 
perinseum, we should imagine it to be the effect of the extravasation of the urine in 
the cellular membrane, and the effect of general irritation, until it is observed that 
the simple stricture produces that effect, and that a touch of the caustic brings on a 
violent paroxysm. 

When the reticular membrane is inflamed, of course it loses its elasticity, and 
gives pain in erection. Sometimes the inflammation, being continued to the spongy 
body surrounding the urethra, makes it unequal in its capacity of distention to the 
cavernous bodies of the penis, and sometimes their cells are united by adhesion in 
the worst cases of chordee. 

I cannot imagine with some, that the urethra is muscular ; first, because I see no 
end it could serve in the economy ; secondly, because there is no proof in support 
of the opinion ; thirdly, because it is surrounded with strong fibres and a spongy 
body, which conjointly seem calculated for every purpose of the economy, and likely 
to account for every symptom which might be mistaken for spasmodic action in the 
canal itself. The idea of muscularity is derived from the symptoms of stricture and 
the irritability of the canal.* 

The urethra is very elastic ; not only allowing a very large bougie to be passed, 
and closing upon a thread, but it still more remarkably admits of elongation than 
of distention in the width of the canal. It is surrounded, as we have seen, with a 
spongy body, and the cellular coat which is betwixt the delicate lining membrane of 
the urethra and the spongy body ; it partakes of the structure of both, and is very 
elastic. But when an inflammation attacks the canal, this cellular membrane is its 
principal seat. The point affected loses its elasticity ; no longer stretches with the 
penis and urethra, but consolidates, or forms a strong membranous filament. To 

* Morgagni describes the membrane of the urethra as double, having vessels betwixt its laminae. 
These are the veins described by Dr. Barclay. Observ. Anat.p. 1, tab. IV. J. C. Brims. Sand. Thes. 
VIII., describes two laminae, one of which he considers to be the continuation of the muscular coat of 
the bladder. See a paper of Mr. Shaw's in the Medic. Chirurg. Trans. 



[•HE TESTES. -i\ 

suppose tliis stricture to have been formed by the muscular contraction in the diam- 
eter of the canal, would be to allow the partial action of one or two fibres ; (for the 
stricture is like that which would he produced hy the tying of a packthread round 
the canal, being a narrow circular ridge ;) which is very unlikely. Sometimes, how- 
ever, the stricture is only on one side of the canal, which, allowing it to he formed 
by inflammation, is very likely to happen : hut in consequence of the muscular action, 
cannot easily he supposed to take place, since the drawing of the muscular fibres 
would equally affect the whole circle. 

As to the effect of heat and cold on an obstruction, it may be explained easily, 
without the supposition of muscular contraction ; for as we know that the spongy 
bodies, and of course the whole canal, relax and elongate in warmth, as they are 
shrunk up and contracted in cold, like the skin of the body in general, without im- 
plying muscular contraction : so we see how this state would affect a stricture ; — 
that, when the penis and the urethra were shrunk, the effect of the stricture would 
be increased, and the patient could pass his urine only when the parts were relaxed, 
by sitting in a warm room, or by the use of the bath. 

But when surgeons speak of spasms of the urethra, they seem to forget the action 
of the surrounding muscles. Thus acrid and stimulating urine, or an irritable state 
of the urethra, will be followed by a small stream of urine ; or perhaps a temporary 
obstruction is the consequence : but why should we suppose that the membrane of 
the urethra, which has no appearance of muscularity, causes this effect when it is 
probably produced by the sphincter muscles, the fibres which surround the mem- 
branous part of the urethra, the levator ani, and, above all, by the accelerator urinse, 
a muscular sheath of fibres surrounding three or four inches of the canal. Round 
the membranous part of the urethra, and behind the bulb, there is much interlacing 
of muscular fibres : and the levator ani, splitting, embraces it. Round the sinus of 
the urethra, and the bulb which covers it, is the accelerator urinse, more properly the 
ejaculator seminis. In short, here is a whole class of muscles which sympathize 
with the state of the urethra ; and these muscles, disordered in their action when 
the canal is inflamed, give occasion to those contractions which are attributed to the 
membrane of the urethra itself. 

THE TESTES. 

The Testicle might be considered as more naturally connected with the abdo- 



32 THE TESTES. 

minal viscera, than with those of the pelvis, as its original seat is on the loins 
amongst the abdominal viscera, and as it receives its coats from the peritoneum, its 
vessels from the abdominal vessels, and its nerves from the plexus belonging to the 

vital parts. 

The testicles are two glandular bodies which secrete the semen ; they are seated 
in the scrotum, and are covered and protected by several coats ; they receive their 
vessels from the aorta and cava, or the emulgent vessels ; their excretory ducts ran 
up into the belly, and terminate in the urethra near the neck of the bladder. 

The Scrotum, in which the testicles are lodged, is a continuation of the common 
integuments ; its cellular membrane is particularly lax and free from fat, and the 
water of the anasarca is extremely apt to fall down into it, so as, sometimes, to dis- 
tend the scrotum to a transparent bag of enormous size ; and not unfrequently the 
cellular texture here has been blown up to counterfeit rupture and other diseases. 

Of the Dartos. — The cellular substance of the scrotum is peculiar in its ap- 
pearance, being red and fibrous. It has been considered as a muscle, and called 
dartos ;* although this is denied by many. Its action is to support and brace the 
scrotum ; and in bad health,! and in old age, is so much relaxed as to allow the 
testicle to hang upon the cords. But besides the simple corrugation and relaxation, 
the scrotum has a motion like the vermicular motion of the intestines, obliquely and 
irregularly from side to side. Its contraction has a relation to the healthy secretion 
of the gland within, and when for some obstinate disease of the body of the testicle 
blisters are applied to the scrotum, we may see this muscle in great activity rolling 
round the testicles. The straight fibres of the cremaster muscle could not, I 
imagine, perform this revolving motion, and therefore, I conclude, that the dartos is 
a muscle on a testimony better than is to be had from dissection. 

There may be traced from the web of cellular membrane which covers the abdo- 
minal muscle, a kind of imperfect expansion descending upon the testicles. This 
becomes very strong when hernia has taken place at the ring. J 

Septum. — Upon the surface of the scrotum, directly in the middle, there is a line 
passing from the lower part of the penis to the anus — the rapha. This line marks 

* Veterum. 

t Nurses attend to the state of the scrotum in children. 

% Mouchart de hern. p. 14, tab. 2, Garengeot. Holler. Monro. — I have, during operation, separated 
this into three laminae. 



THE URETHRA. U 

a division in the scrotum, a partition, or septum, which divides the scrotum into two 
distinct cellular beds for the testicles. 

Coats of the TESTICLE.* — The (remaster muscle is expanded over the proper 
coats of the testicle. The origin of this muscle is from the internal oblique muscle 
of the abdomen. It passes through the hole of the external oblique muscle called 
the ring, and descends over the vessels to the testicle, constituting a part of the cord 
and finally spreading its fibres over the tunica vaginalis testis. Its use is to suspend 
and draw up the body of the testicle. 

Under the fibres of the muscle, we may discover a process of cellular membrane 
which comes down from the cellular membrane behind the peritoneum, and has 
been usually called a process of the peritoneum, even before the coats of the testi- 
cle were discovered to be originally formed by that membrane. 

Besides the involving scrotum, each testicle has distinct coats. The tunica 
vaginalis, according to our best authors, covers the testicle loosely ; that is, with- 
out adhering to its general surface : but the albuginea is in close union with it, and 
is the immediate coat of the testicle. The inner surface of the vaginal coat is per- 
fectly smooth, and an exudation is poured out from it, as from the peritoneum within 
the belly. The outer surface of the tunica albuginea is also smooth and firm, and 
white, whence its name ; but on its inner surface, like the peritoneum, which covers 
the intestine, and adheres to the muscular coat, it adheres to the proper substance 
of the testicle. These investing coats are, in some respects, dissimilar, yet in gen- 
eral much alike, one being continued into the other, and both prolongations of the 
peritoneum. The outer membrane, the tunica vaginalis, is a protection to the testi- 
cle by gliding easily on the inner coat ; and aided by the mobility of the cellular 
membrane of the dartos, it preserves the testicle from bruises and strokes to which 
it would be exposed if it were more firmly attached. The inner tunic, or albuginea, 
gives strength to the substance of the testicle. Betwixt these coats is the fluid col- 
lected, which forms the hydrocele. They also contain the congenital hernia ; but 
the common hernia is without both coats of the testicle. To understand the 

* Dr. W. Hunter discovered the situation of the testes in the abdomen of the foetus, and suggested 
this to his brother as a subject of investigation. Mr. J. Hunter distinctly described the anatomy of the 
descent of the testicle, and explained the formation of its coats. See his Animal Economy. In reading 
Kirckringius, one is apt to believe he understood the nature of the descent of the testicle. Spicilegium 
Anatomicum, p. 35. 



34 THE DESCENT OF THE TESTICLE. 

anatomy of this part thoroughly we must attend to the descent of the testicle, and 
to the manner in which these coats are formed. 



THE DESCENT OF THE TESTICLE. 

Ijv the foetus, some months before birth, the testicles are lodged in the belly, and 
are, in every respect, like the abdominal viscera. They are seated on the fore part 
of the psose muscles by the side of the rectum. They are covered and invested by 
the peritoneum ; for as we have explained how the solid viscera and the intestines 
are behind the peritoneum, so it will be understood how the testicle lying on the 
loins are behind the peritoneum : that is to say, the glandular substance of the testi- 
cle is invested by a coat, and that coat is the peritoneum, which, after covering the 
body of the testicle, is reflected upon the loins ; as the coats of the liver, for example, 
are to be traced from its surface to the diaphragm. 

We have explained the change which takes place in the situation of the testicle, 
as it relates to the peritoneum ; but how this change is brought about, it is veiy 
difficult to understand. It is not a sudden pulling down of the testicle, but a very 
gradual process, continuing for months : it is not the effect of gravitation, for the 
foetus may be in every variety of posture while in the womb, and generally the head 
presents. It is not respiration. Is it then the effect of the action of the cremaster 
muscle 1 or must we refer it to a law such as that which controls and directs the 
growth of parts 1 

When the parts in a foetus before the descent of the testicle are dissected, there 
is found a ligamentous, or cellular cord, mingled with the fibres of the cremaster 
muscle, and which takes its origin from the groin, is reflected into the abdominal 
ring, and stretches up to the body of the testicle. This body is called ligament, or 
gubernaculum, and to the agency of this bundle of fibres, is the descent of the testi- 
cle attributed. There are, however, objections to this. If we suppose that the cre- 
master muscle, by its exertion, brings down the testicle to the ring, how does it pass 
the ring 1 For surely we cannot suppose that this muscle, which takes its origin 
from the internal oblique muscle, consequently within, can contract, not only so as to 
bring the testicle to the very point of its origin, but to protrude it past that point, 
and through the tendon of the external oblique muscle. Animals have the cremaster 
muscle, whose testicles never descend out of the belly ; — again, the vessels of the 



THE DESCENT OF THE TESTICLE. 85 

cord, before the testicle lias fully descended, show no marks of being drasffed down, 
for they arc elegantly tortuous. 

As the testicle passes veiy slowly from the loins to the ring; ho, after it has 

escaped from the holly, it passes slowly from the ring to the bottom of the scrotum. 
It commonly remains some time by the side of the penis, and only by degrees 
descends to the bottom of the scrotum.* 

In this change the testicles do not fall loose into the elongation of the peritoneum 
like a piece of gut or omentum in the rupture ; — but carrying the peritoneum with 
them, they continue to adhere to the parts behind them, as they did to the psoas 
muscle while in the loins; a point of importance to be recollected. 

The communication betwixt the belly and the sac of the vaginalis, is very soon 
obliterated by the adhesion of the upper part, and then the whole extent of the pas- 
sage is shut. When this process is prevented in the first instance, and nature is 
baulked in the humor of doing her work, as Mr. Hunter observes, she cannot so 
easily do it afterwards. 

It has also occurred, that this communication remaining after birth, a hydrocele 
has been produced, owing to the distention of the tunica vaginalis, by fluids descend- 
ing from the belly. The character of such a tumour will be, that the fluid may be 
easily forced into the belly. It may be mistaken for a congenital hernia. 

It will already be understood, that in the common hernia of the groin or scrotum, 
the gut does not pass by the communication from the belly into the vaginal coat ; 
that such communication no longer exists, and that when there is a rupture from 
preternatural wideness of the abdominal ring, or in consequence of a great violence, 
a new portion of the peritoneum descends with the gut before the cord of the testicle. 

When we dissect the coats of the adult testicle, we can follow the tunica vaginalis 
over the surface of the testicle, and by dissecting, separate it from the testicle, leav- 
ing that body covered by a dense membrane. Specimens may be seen in my Col- 
lection, where hydatids, forming betwixt these membranes, have separated them in a 
manner still more satisfactory than can be done by dissection. What terms are we 

• Mr. Hunter has shown, that the detention of the testicle in the belly is in consequence of bome 
defect and want of action in the testicle, and that those who have the testicle remaining in the belly have 
it imperfect or small. This is contrary to an old authority : — The testicles are seated externally, " for 
chastity's sake ;" for such live wights as have their stones " hid within their body, are very lecherous, 
do often couple, and get many young ones." 



36 THE VESSELS OF THE CORD AND TESTICLE. 

to use for these three membranes 1 1. tunica vaginalis ; 2, tunica vaginalis 
rejlexa ; and 3. tunica propria testis.* 

THE VESSELS OF THE CORD AND TESTICLE. 

In attending to the descent of the testicle, we have a clue also to the vascular 
system. If we did not know that the testicles were originally placed in the loins 
within the belly, we might wonder at the length and origin of the spermatic vessels. 

The Sperjiatic Artery rises on one side from the fore part of the aorta, below 
the emulgent artery, and on the other from the emulgent artery, sometimes they arise 
from the arteries of the renal capsule ; sometime there are two spermatic arteries to 
one testicle. This artery, which the cord receives from the aorta or emulgent, is 
called the superior spermatic artery, because there is another which rises from the 
hypogastric artery ; this branch runs upward, connected to the vas deferens, as it 
rises out of the pelvis. Another artery is given to the membranes of the testicle 
from the epigastric artery. 

These arteries, taking their course under the peritoneum, join the fasciculus form- 
ing the cord, and supply the cord, and send twigs to the investing peritoneum ; they 
then pass through the abdominal ring, and in their course they are beautifully 
tortuous. 

The Veins of the testicle terminate on the right side in the trunk of the cava, a 
little below the emulgent vein, and in the emulgent vein on the left side. There is 
also (accompanying the vas deferens) a vein, which joins the internal iliac vein; All 
these veins, in their course from the testicle, are protected from the column of blood, 
and from the consequences of compression, by numerous valves. These valves are 
very strong, and will bear a great column of mercury before they give way or burst. 
This plexus of convoluted veins of the cord is the most beautiful in the body ; and 
we may observe, that such convolutions of veins are ever attendant on arteries tor- 
tuous in their course, and subject to occasional excitement. And further, if by acci- 
dent there is excited an uncommon action in the arteries of a living body, that action 

* De Graaff speaks of the division of the tunica albuginea into two membranes, probably meaning to 
distinguish the cellular tissue of the body of the testicle from the investing membrane. Morgagni, in 
his commentary on him, tells us he can separate the tunica albuginea into two lamina, the inner of 
which was the most delicate. Advers. An. iv. Animad. i. 



THE VESSELS OF THE CORD AND TESTICLE. 



37 



will be apparent from the distended or enlarged state of the veins. In the testicles 
of such animals as have their seasons, the artery and veins of the testicle become 
still more convoluted, and form a mass of vessels, which has been called corpus 
pyramidal e.* 




EXPLANATION OF PLATE. 

1. Symphisis 'pubis. 2. Anterior and superior spinous process of the ilium. 3. External oblique 
muscle. 4. Linea alba. 5. Lineae semilunares. 6. Abdominal rings. 7. Origin of some tendinous 
fibres. 9. Poupart's ligaments. 11. Fascia lata of the thigh. 12. Saphena major vein of the leg. 
13. Fascia which arises from Poupart's ligament and joins the fascia lata. 14. Tendon of the external 
oblique muscle. 15. Internal oblique muscle. 16. Transversalis muscle. 17. Internal inguinal ring. 
18. Epigastric artery and vein. 19. Spermatic cord, formed by the spermatic artery and veins, the lym- 
phatics of the testicle, the nerves, and the vas deferens, or the duct conveying the semen from the testi- 
cle to the urethra, which it enters through the prostate gland near the neck of the bladder. 

The nerves of the testicle, like the blood-vessels, come from the loins ; they form 
a division from the emulgent plexus, and are continued down upon the vessels. 

* Corpus varicosum. — Corpus Pampiniforme ; Alias parastatum varicosum ; Galen de Semine ; 
Util. partium. — As the old physiologists saw and observed this wonderful tortuosity, and the tendril- 
like form of the spermatic artery, they thought that the blood was here begun to be changed into semen, 
and therefore they called them the vasa prceparantia. 



38 THE STRUCTURE OF THE TESTICLE. 

This connects the testicles to the abdominal viscera, giving them much of the same 
sympathies. The stomach, intestines, and testicle, sympathize readily with each 
other. 

The lymphatics of the testicle are numerous, and easily demonstrated by blowing 
up the cellular structure of the body of the testicle ; and this has been the ground of 
dispute between physiologists ; and the proofs of some important points in the doc- 
trine of absorption have been drawn from the injection of the lymphatics of the tes- 
ticle and cord. 

The Cremaster Muscle takes its origin from the internal oblique muscle of 
the abdomen, from the os pubis, and, passing down over the vessels of the cord, 
is expanded on the tunica vaginalis. The use ascribed to it is to suspend the tes- 
ticle, and prevent it from dragging upon the vessels of the cord ; but it is chiefly 
useful in compressing the body of the testicle, drawing it up, and accelerating the 
discharge of semen. A very principal use is to compress the veins of the cord, and 
to support them against the impulse from within. 

Thus we find the cord of the testicle, as it is called, to consist of the excretory 
duct ; of the arteries, veins, and nerves ; of the lymphatics returning from the testi- 
cle ; of the cellular tissue embracing and supporting all these vessels ; and lastly, of 
the fibres of the cremaster muscle. 

THE STRUCTURE OF THE TESTICLE. 

It is to De Graaff that we owe the knowledge of the structure of the testicle ; and 
indeed the merit of this great anatomist has not been acknowledged with sufficient 
gratitude by modern anatomists : but after the fervor of disputation has subsided, 
the merit of ingenuity and of discovery must return to him to whom it is due. No 
one more highly values than I do the improvements of anatomy by the Hunters and 
Monro ; but I must say, that the structure of the testicle was demonstrated by De 
Graaff to his fellow anatomists of Montpelier ; and his discoveries published in a 
manner so perfect, as to leave us little to learn from more modern authors. 

De Graaff, by exciting the gland of brutes, and tying the spermatic cord, had the 
seminal vessels distended. He did not depend upon injections ; by maceration and 
dissection in this distended state, he unravelled all the intricacies of their tubes. 
More modern anatomists have proved the truth of his observations by injections of 
mercury, and have succeeded in a variety of ways of preparing the testicle. 



THE STRUCTURE OF THE TESTICLE. 39 

Tubuli Testis. — When the tallica propria testis is lilted, the body of the testi- 
cle is found to consist of innumerable delicate white tubes; winch, when disentan- 
gled from the minute cellular membrane which connects them, and floated in water. 
exhibit a most astonishing extent of convoluted vessels. By a closer attention, how- 
ever, to this structure, before it is thrown into confusion by pulling out the tubes, 
they appear to be regularly laid in partitions of the cellular membrane. These 
septimenta are very regular in some animals, and while they separate the seminal 
tubes, they support and convey the blood-vessels for the secretion of the semen. Dr. 
Munro has denied the formal divisions which De GraafF had engraved, but admits 
them less regular, less easily found, and not so limited in number ; nor does he find 
that they prevent all communication betwixt the tubes of the testicle. 

These seminiferous tubes of Haller, or tubuli testis of Monro, run towards the 
back of the testicle. Each of these tubes seems to be cylindrical, or of one diame- 
ter throughout their whole extent : we see no communication betwixt them ; no 
branches given out or going into them ; nor have I been able to distinguish a be- 
ginning for the whole, nor for any one of them. There seems to be only one tube 
wonderfully convoluted and folded up in each subdivision of the testicle. 

Rete Testis. — When the tubuli come out from the body of the testicle, they 
run along the back of it and communicate by inosculations with each other, so as to 
form a net-work of vessels, from which appearance Haller named them rete testis. 

Here it often happens, that the mercury stops, when it has been injected back- 
wards from the vas deferens ; and it is this part which has been better described 
and drawn, in consequence of mercurial injections, than it was by De GraafF; for he, 
as we have said, saw this part only filled with semen. 

Connected with the rete testis is the Corpus Highmorianum. — Where the lines 
of the membranous septa, and cellular membrane of the testicle meet on the back 
of the testicle, and under the epididymis, they form a white line. This white line 
running along the testicle, was supposed by Highmore to be a hollow tube ; it was 
compared with the salivary duct ; it was thought to be a cavity leading from the 
body of the testicle to the head of the epididymis, and to form the communication 
by which the semen flowed from the testicle. De GraafF first refuted this notion, 
and showed that it was not by this one great duct, but by these smaller tubes form- 
ing what has been now called the rete testis, that the semen came from the testicle : 
still it had continued a question, whether this white line was really solid, or a tube ; 



40 



THE STRUCTURE OF THE TESTICLE. 



and upon faithful examination of the point it appears, that this is expressly as it was 
explained by De Graaff, viz., that it is a mere collection of the membranes of the 
body of the testicle, forming linea alba ; and as the septa are more distinguishable 
in some animals, so is the corpus Highmorianum.* 

Vasa Efferentia. — The tubes running on the back of the testicle, and forming 
the rete testis, we have understood to arise from the tubuli testis ; now it is the con- 
tinuation of the rete testis which is called vasa efferentia. The vasa efferentia are 
very delicate vessels which run out from the head of the testicle, single at first, but 



FIGURE 1. 



FIGURE 2. 




gJJTgS- 




EXPLANATION OF PLATES. 

Figure 1, delineates the human testis injected with mercury. 1. Lobules formed by the seminifer- 
ous tubes. 2. The vasa efferentia. 3. The flexures of the efferent vessels passing to the head of the 
epididymis — marked 4. 5. The body of the epididymis. 6. Appendix. 7. The cauda. 8. The vas 
deferens, or seminal duct. 

Figure 2, is a plan of the structure of the testes and epididymis, showing the seminiferous tubes 
which convey the semen from the tubuli seminiferi, and discharge it at last into the vas deferens, or 
great seminal duct, that terminates in the prostatic portion of the urethra. 3. Seminiferous tubes ; * * 
* * their anastomoses. 4. Rete testis. 5. Head of the epididymis. 6. Body of the epididymis. 
7. Vas deferens, or great seminal duct. 8. Cauda. 9. Appendix. 10. Vasa efferentia. 11. Flexures 
of the efferent vessels passing to 5, 5, the head of the epididymis. 



This body is called a mere firmamentum or binding. — Winslow. 



THE STRUCTURE OF THE TESTICLE. 41 

they are soon convoluted, and by these convolutions they are formed into an equal 
number of vascular cones, which constitute the head or larger part of the epididymis. 
These vasa efferentia and vascular cones are connected by a very delicate cellular 
membrane ; and it is a piece of very nice dissection to display them after they 
are injected with mercury. 

Epididymis. — The vasa efferentia, after forming these conical convolutions, unite, 
and form larger tubes ; these again unite, and form one large excretory duct, the 
vas deferens; and this vessel, being convoluted to a wonderful degree, forms a body, 
which, being as it were placed upon the testicle, has been called epididymis. 

In the substance of the testicle there are no glands nor follicles ; the arteries min- 
utely ramify amongst the seminal tubes, and, there is reason to believe, secrete the 
semen into them. The seminal vessels in the substance of the testicle, or tubuli 
testes, ran together upon the surface of the testicle, and form the rete testis. From 
the rete testis are continued the vascular cones : these convolute, and running 
together, form the epididymis ; from which the tube is continued under the name 
of the vas deferens. It passes up the cord, enters by the ring into the abdomen, 
and then, passing down into the pelvis, terminates in the vesiculss seminales, in a 
manner presently to be explained. It is not likely that the vis a tergo, the power of 
the arteries, pushes the semen through all this length of tube, of which the epididy- 
mis itself is reckoned to be several feet in length if the various convolutions were 
undone ; such an action on the testicle as that of the dartos or cremaster muscle, 
could give only a general pressure, but could not force on the semen in tubes which 
take so great a variety of directions. We are therefore left to the supposition, that 
these tubes themselves have a power of accelerating the fluids through them. 

There is a duct which sometimes arises from the epididymis, and which we find 
to terminate abruptly in a blind end — of this, Mr. Hunter speaks in the annexed 
note.* ^ 

* " By a supernumerary vas deferens, I mean a small duct, which sometimes arises from the epididy- 
mis, and passes up the spermatic cord along with the vas deferens, and commonly terminates in a blind 
end, near to which it is sometimes a little enlarged. I never found this duct go on to the urethra, but, 
in some instances, have seen it accompany the vas deferens as far as the brim of the pelvis. There is 
no absolute proof that it is a supernumerary vas deferens ; but as we find the ducts of glands, in general, 
very subject to singularities, and that there are freqiiently supernumerary ducts, there being often two 
ureters to one kidney, sometimes distinct from beginning to end, at other times both arising from one 



42 



THE TESTICLE IN GENERAL. 



THE TESTICLE IN GENERAL. 

The testicle is of an oval form, and of the size of a pigeon's egg ; it is a little 
flattened on the sides : it hangs in the scrotum by the spermatic cord ; one end of 
the oval, forward and high. The spermatic cord consists of the artery which brings 
blood ; of the veins which return it ; of the vas deferens, which carries the semen to 
the vesicular seminales at the neck of the bladder ; of lymphatics, which are essential 
to the structure of every part. This cord of vessels comes down from the belly, and 
passes by the ring of the abdominal muscles ; it is about four inches in length, and 
is fixed into the upper and back part of the body of the testicle. 

HUMAN SPERMATOZOA. 




EXPLANATION OF PLATE. 

1. The spermatozoa; they are quite transparent, and consist of a flattened head and a large taper- 
ing tail. 2. Seminal granules, from which the spermatozoa are developed. 3. The spermatozoa from 
the developed granules, lying side by side within the vesicle, which change from a sphere to a long 
oval. After a time they break forth, but still adhere to each other for a short period, forming a bundle. 

pelvis : these ducts arising from the epididymis, I am inclined to believe, from analogy, are of a nature 
similar to the double ureters. They resemble the vas deferens, as being continuations of some of the 
tubes of the epididymis, are convoluted where they come off" from it, and afterwards become a straight 
canal passing along with it for some way, when they are commonly obliterated. 

" The idea of their being for the purpose of returning the superfluous semen to the circulation is cer- 
tainly erroneous, from their being so seldom met with, and so very seldom continued further than the 
brim of the pelvis." 



THE VESICULSE SEMINALES- 48 

The body of the testicle is easily distinguished, and is the place where the secre- 
tion is performed. It is strictly the body of tin; gland, while the part above it is 
only the duct by which its Moid is discharged. 

Before the years of puberty, the testicles secrete a viscid, milky fluid, which does 
not possess the qualities of semen. At the age of puberty, the semen is secreted 
and a revolution at once commences in the whole system. The voice becomes 
manlike ; the beard is developed ; the bony and muscular systems are increased, 
and the boy at length emerges into manhood. All these striking changes are 
evidently connected with the new secretion of the seminal fluid, and indeed, the 
removal of the testicles prevent them from taking place, as is seen in the case 
of eunuchs. 

THE VESICULJE SEMINALES. 

Behind the prostate gland, and attached to the lowest part of the urinary blad- 
der, lie two soft bodies, the vesiculse seminales. They appear like simple bags 
when seen from without, but dissections show them to consist of a cellular structure ; 
each of these bodies is about three fingers-breadth in length ; their backmost point 
is large and round, and, at the same time that they diverge from each other, their 
narrow points unite, or are contiguous to each other forwards, and enter at the back 
part of the base of the prostate gland. 

As we have seen, the peritoneum does not descend far enough betwixt the blad- 
der and rectum to cover or invest these vesiculse ; they are therefore involved in the 
cellular texture, and covered with strong fibres, besides being subject to the com- 
pression of the levator ani muscle. When the vesiculse are cut into, and especially 
when they are distended, dried, and cut, they appear cellular ; but if they are care- 
fully dissected, they present the appearance of a convoluted duct. 

This cellular appearance is produced by the duplication of their inner membrane, 
together with the distortions and curves of the canal. Their outer surface is covered 
with a fine membrane, which connects these cellular convolutions. 

The vesiculse are copiously supplied with arteries : their surface is covered with 
veins and lymphatics. Heister, Winslow, and others, have described small glands 
seated in their sinuosities ; but these are confidently denied by others. "These 
vesiculse are themselves glands, or in other words, the arteries secrete into them a 
peculiar fluid. The fore part of each of the vesiculse, which we have said sinks 



44 THE VESICULJE SEMINALES. 

into the back part of the prostate gland, runs under the neck of the bladder, and 
opens by a distinct mouth into the urethra, on the surface of the verumontanum. 

The connexion of the vas deferens with the'vesiculae is very particular: the duct 
and the extremity of the vesicular tube join, and they together open into the urethra. 

There is nothing in the human structure to discountenance the idea that the 
semen may pass retrograde from the vas deferens into the vesiculse seminales, but, 
as in some brutes, the vas deferens has no connexion with the vesiculse seminales, it 
is to be presumed that they are not mere receptacles of the secretion of the testicles. 

The extremity of the vas deferens joins the duct of the vesiculse where it is im- 
bedded in the prostate gland ; the union of the vas deferens and duct of the ve- 
sicular is not attended with an enlargement of the duct ; on the contrary, as the duct 
passes forward deep into the substance of the gland to arrive at the urethra, it be- 
comes remarkably narrower until it opens in a very small orifice in the verumonta- 
num. The duct (if we may so call it), of the vesicular passes a considerable way 
into the gland before it terminates in the urethra. 

The vesiculse appear to be useful in adding a fluid to the secretion of the testicle, 
which be ing poured together into the sinus of the urethra, are then sufficient to dis- 
tend this part of the canal by which the ejaculator muscle is excited, and effect given 
to its action ; for a smaller portion of fluid would not be carried forward by its con- 
traction. Unless there were a provision of fluid sufficient to distend the sinus of the 
urethra, the semen could not be thrown out from the urethra. This supposition is 
not opposed by the facts stated by Mr. Hunter, that in many animals the vesiculse 
and vasa deferentia open by distinct foramina into the urethra, because in that case 
the fluids of these secreting bags might be equally mingled with the semen in the 
sinus of the urethra, although they do not flow from the same tube. 

Verumontanum. — The verumontanum, or caput gallinaginis, is an eminence on 
the lower part of the urethra, where it is surrounded by the prostate gland. It is 
larger and round towards the bladder, and stretches with a narrow neck forwards. 
On its summit, the two orifices of the seminal vessels open ; and around it there 
are innumerable lesser foramina and mucous follicles, the ducts of the prostate gland. 

The Sinus Pocularis is the sac or large lacuna formed within the caput gallina- 
ginis ; its mouth is directed forwards, so that the urine flowing out of the bladder 
lays the margin down, and as the seminal orifices open within the margin, they are 
by this means protected from the urine. Sometimes the ducts are found opening 
on the sides of the sinus. 



CHAPTER II. 

ANATOMY OF THE FEMALE PARTS OF GENERATION. 

tx- . -*~; ---O 1111U l~ 

The Anatomy c ^ ^ .^ ^ ^ ^^ ^ ^ ^ ^ ho Urethra. -Parts 

contained within * shape, connexions, 

&c — The Uterus' atheter ' on the end of tne midclle finger from i 

lacuna-like orifice of the urethra. 
The parts of th and sudden turns of the male urethra, from those without 

the pelvis ; and from its being embraced by the prostate glanc within the bony 
circle of the true :>re frequent, and the catheter less easily pass 
), requires to be of a very peculiar form. r 
a requires only a simple and almost straight 
L it to the course of the urethra, a consider,-: 

The external parts of generHi^ii^.vC^ue'mons veneris, labia, clitoris, nymphse, 
urethra, hymen, and carunculee myrtiformes. Upon these subjects we have no 
want of books and information ; for accoucheurs of the old school dwelt upon the 
description with particular accuracy. These parts were within their ken, which 
we cannot say of the viscera of the pelvis : and therefore upon this first head 
we shall be more brief. 

In very young children these external parts bear a large proportion to the body, 
greater than at any subsequent period before the age of puberty. From the age of 
two years to twelve or thirteen, there is little increase. At puberty they are suddenly 
completely evolved. Preceding menstruation and the development of the uterine 
system, the whole parts, internal and external, partake of a sudden impulse. They 
become turgid and vascular; the fat is deposited in the surrounding cellular 
membrane. 

About the fortieth year, when the menses disappear, this fulness of the private 
parts also ceases, and the fat is re-absorbed. 

The Mons Veneris is that prominence on the symphysis pubis, which consists of 
the skin raised and cushioned up by the fat inclosed in the cellular membrane. 



46 THE EXTERNAL PARTS OF GENERATION. 

There is a great variety in the size. In early life it is small : it becomes, as we 
have said, more prominent at the age of puberty ; in fat women it is of an enormous 
size : and in some warm climates a particular laxity prevails. From the hair on 
this part, marking the age of puberty, it is called pubes. As the lax texture admits 
of distention with the fluid of anasarca, it is sometimes from this cause very greatly 
swelled. 

,1 that they are not mere receptacles of the secretion or 
' of the vas deferens joins the duct of the vesiculee 
prostate gland; the union of the vas deferens an< 
jended with an enlargement of the duct ; on the con 
deep into the substance of the gland to arrive at tl 
bly narrower until it opens in a very small orifice ir 
ct (if we may so call it), of the vesiculse passes a 
Defore it terminates in the urethra, 
'ae appear to be useful in adding a fluid to the secretin 
^nred together into the sinus of the urethra, ar^ ' 



Xjyvi iv— 



External Organs of Generation in the Unmarried Female, the Labia Majora being closed. 

1. T,ar»ia Majora. 2. Rima or Fissura Vulvas. 3. Fourchette — Posterior Commissure. 
4. Anterior Commissure. 5. Perinaeura. 6. Mons Veneris. 

The Labia. — These are often named alas, from a slight resemblance to wings, 
and they are also called alas extern*, magnse, or majores, from their place, and 
from their superiority in size over the nymphas. The labia seem to be the 
mons veneris continued downward and laterally, until meeting below, they 
complete the circle of the vulva ; at their lower angle by their union they form 
the fourchette, or freenum labiorum. The structure of the labia is similar to 
that of the mons veneris ; sometimes one is larger than the other. 

The great sensibility of the membrane which lines the inside of the labia requires 
some defence, and therefore the whole surface is amply supplied with mucous folli- 
cles and glands. The labia are a protection to the other soft parts. If the clitoris 
or nymphse project beyond them, they are subject to violent inflammation. 

The parts here have either such folds, or are of so lax a texture, as to permit a 



THE EXTERNAL PARTS OF GENERATION. 47 

great degree of distention during the passage of the child. Hut as the labia have 
no muscular power, and depend entirely on their elasticity Cor restoring them to their 
original size, they commonly, after being very much dilated, remain in some degree 
larger and more lax. It is different with muscular parts, as the orificium externum, 
which, by the power of its sphincter, is restored after labor to its original size. In 
man, hernia descends from the abdominal ring into the scrotum ; but, in woman, 
when there is a rupture from the ring, (which is rare) it falls into the labium. 

erved, there is. in the natural state of the pan?*, ... 

he catheter, on the end of the middle finger from i 
the lacuna-like orifice of the urethra, 
length and sudden turns of the male urethra, from 
>nd from its being embraced by the prostate glanc 
j more frequent, and the catheter less easily pass 
r, too, requires to be of a very peculiar form. r 
Dman requires only a simple and almost straight 

adapt it to the course of the urethra, a considerf 
et that is not necessary in common cases ; and circ 

EXPLANATION OF PLATE. 

A View of the E eternal Organs of Generation in the Unmarried Female. 

1. Labium Majorum. 2. Fourchette. 4. Prepuce Clitoridis around the glans clitoris. 5. Vesti- 
bulum. 6. The Nymphge. 7. Points to the Meatus Urinarius. 8. The Hymen. 9. The Perineum. 

The Nymphje are named labia vel alee, or labia interna, to distinguish them from 
the great labia. They are like a miniature representation of the great labia ; they 
are covered with a very delicate membrane, and have great sensibility. They be- 
gin immediately under the glans clitoridis, and seem to be only an extension of its 
praeputium, formed by a folding of the membrane. Their size varies much. They 
commonly stretch downward and backward to the middle of the orifice of the va- 
gina ; sometimes no further than to that of the orificium urethrse, and in a few 
instances they extend even in the length of the fourchette.* They are very 
vascular and have somewhat of a cellular structure, and thus partake of a degree 

* Both Riolin and Morgagni have seen the parts without the nymphae. 



48 



THE URETHRA. 



of turgidity, in consequence of irritation and vascular action. The most modest 
of the uses ascribed to them is, that of directing the stream of urine. As they are 
obliterated during the passage of the child's head through the vulva, it is probable 
that they facilitate the necessary dilatation. 

The nymphse are, in their natural situation, covered and completely protected by 
the labia externa. When naturally large or increased by disease, or in a very 
relaxed state, they are deprived of this covering : they project from under the 

labia and are apt to become inflamed and even to ulcerate. Tljg^riginal disease or 

tumor, is augmentedhe vas deferens joins the duct of the vesiculse children they 
bear a very great ate gland ; the union of the vas deferens an. 
prominent than in d with an enlargement of the duct ; on the cor. 
to be extirpated, iri into the substance of the gland to arrive at ti 
growth their blood-arrower until it opens in a very small orifice i: 

The Clitoris is we may so call it), of the vesiculse passes a 
for receiving blood ; it terminates in the urethra, 
rami of the os pubiar to be useful in adding a fluid to the secreti 
body of the clitoris, together into the sinus of the urethra, ar^ 

of ligament. The ~~, x^S£ ^. &i ~ , _. 

make a fold like a prseputium. In short, it has the same sensibilities, the same 
power of erection with the membrum virile ; only it has no urethra nor spongy body, 
like that of the urethra of man, and is so small as to be hid within the labia. 

The stories of the increase of this, even to its pre-eminence in size over the penis, 
are very idle. It is not wonderful that a clitoris of such magnitude should suggest 
the idea of a hermaphrodite, or a person partaking equally of the distinguishing at- 
tributes of either sex. 



ispicuous and 
times require 

as with their 
expected, 
isists of cells 
5 hold of the 
s, to form the 
nis, by a kind 

integuments 



THE URETHRA. 



The urethra of the female is short, straight, and wide ; its length an inch and 
a half, or two inches ; its direction nearly straight, or only slightly bending under 
the os pubis ; and its diameter such as will admit a catheter the size of a writing 
quill. The consequences of these peculiarities are, that the catheter is easily 
passed when there is no very unusual obstruction ; that women are not so much ex- 
posed to the disease of stone in the bladder as men, for though this is much owing 



THE URETHRA. 49 

to constitutional peculiarities, yet it is obvious, that when a small stone is formed, 
and passes into the bladder, it is more easily discharged in this sex. If it docs not 
pass with the flush of urine, yet the canal can be dilated, so that a very considerable 
calculus may be discharged without incision. 

The opening of the urethra is in a direct line under, or behind the clitoris, and 
about an inch from it ; it is in the middle of a slight prominence, and its vicinity 
is plentifully supplied with mucous glands. If the relation of the orifice to the 
clitoris be observed, there is, in the natural state of the parts, no difficulty in slipping 
the point of the catheter, on the end of the middle finger from the clitoris, until it is 
caught upon the lacuna-like orifice of the urethra. 

From the length and sudden turns of the male urethra, from the double function 
it performs, and from its being embraced by the prostate gland, the obstructions of 
the urine are more frequent, and the catheter less easily passed, than in woman. 
The catheter, too, requires to be of a very peculiar form. The short and wide 
urethra of woman requires only a simple and almost straight tube : and although 
accurately to adapt it to the course of the urethra, a considerable curve might be 
given to it, yet that is not necessary in common cases ; and circumstances will occur 
to the accoucheur, which will preclude the possibility of using such an instrument. 

We shall only mention here such cases of obstruction of urine as are in a par- 
ticular manner illustrated by the anatomy and connexion of the parts. These are 
tumors of the ovarium, tumors of the womb, polypi, distention of the vagina, dis- 
placement of the womb, as procidentia, prolapsus, retroversio, &c. ; and lastly, the 
child's head, in labor. 

The ovarium being enlarged, and falling down into the pelvis, either presses upon 
the neck of the bladder, causing obstructions, or pressing and weighing on the 
fundus of the bladder, it occasions a stillicidium urinse. 

Tumors of the womb, especially of the neck or orifice, as it is in contact with the 
urethra, very soon affect this organ. Thus I have seen a cancer of the orifice of 
the womb, by exciting inflammation in all the surrounding parts, and by massing 
them together into a tumor filling the pelvis, occasion obstinate obstructions of 
the urine. 

Polypi attached to the orifice of the womb, and filling the vagina, produce the 
same effect. In all such cases, perhaps the tumor may be pushed up, so as to 
permit the flow of the urine, or the introduction of the catheter. 



50 



THE URETHRA. 



A case occurred to John Bell, in which the tumor of the womb compressed the 
neck of the bladder. A catheter was passed, and gave instant relief. The midwife, 
after some time came, and said the catheter would not pass. He found that he 
could pass the catheter into the bladder, but no urine flowed ; and it was discovered 
that the tumor, increasing backward, came to press upon the ureters, so as com- 
pletely to obstruct them where they enter the bladder. The woman unavoidably 
died : each kidney and ureter was found to contain four or five ounces of urine. 

A sketch of the parts in the female pelvis will, perhaps, better explain the con- 
nexions of the neck of the bladder than any description, and will certainly better 
illustrate the cause of some kinds of obstruction, particularly that arising from the 
change in the posture of the womb. 




EXPLANATION OF PLATE. 



A Side View showing a portion of the Internal Female Organs of Generation. 



1. Symphisis pubis. 2. Abdominal parietes. 3. The fat forming the mons veneris. 4. The bladder 
6. Entrance of the left ureter. 6. Canal of the urethra. 7. Meatus urinarius. 8. The clitoris and 
its prepuce. 9. The left nympha. 10. The left labium majus. 11. The orifice of the vagina. 
12. Its canal and transverse rugae. 13. The vesico-vaginal septum. 14. Vagino-rectal septum. 
15. Section of the perineum. 16. Os uteri. 17. Cervix uteri. 18. Fundus uteri. 19. Rectum. 
20. Anus. 21. Upper portion of the rectum. 22. Recto-uterine fold of the peritoneum. 23. Utero- 
vesicle reflection of the peritoneum. 24. Peritoneum reflected on the bladder from the adominal 
parietes. 25. Last lumbar vertebra. 26. Sacrum. 27. The coccyx. 



THE URETHRA. 51 

The retroversion of the womb is the most formidable obstruction to the urethra. 
It is produced by distention of the bladder acting on the womb in a particular 
situation, and is the cause of suppression of the urine. When the womb in the 
tlnrd or fourth month of gestation has increased so much as to produce a degree of 
compression on the surrounding parts, and to rise above the brim, and shoot up 
into the abdomen, a distention of the bladder is apt to throw the fundus under the 
projection of the sacrum. We have to observe the connexion betwixt the back 
and lower part of the vagina. By the distention of the bladder, the vagina is 
stretched, and the orifice of the womb is raised, which throws back the fundus of 
the womb, so that this comes to be the situation of the parts. 

Now, when the fundus of the wo.nb is thrust back, and the orifice raised by the 
distention and consequent rising of the bladder, the natural and simple cure is to 
introduce the catheter, and draw oflf the urine. But should this not be done at 
first, then there being distention of the bladder, and pressure on the rectum, the 
abdominal muscles sympathise with these parts, so that bearing-down efforts are 
made, and the fundus of the womb is forced further down into the hollow of the 
sacrum while the orifice is directed upward. 

Were this distention to happen at any other time than just when the uterus is of 
such a size, that being thrown back, it catches under the sacrum, and does not rise 
again, no harm could follow. I attended a woman afflicted with obstruction of 
urine, who died. I afterwards opened the body, and found that the womb being 
enlarged by disease had produced much the same effect as if it had been enlarged 
by pregnancy, viz., obstruction of the urethra ; for the body of the womb had fallen 
into the hollow of the sacrum, and had formed adhesions there with the rectum 
while the orifice of the womb pressed forward upon the os pubis, so as to produce 
an obstruction of the urine. The parts were otherwise diseased, but this was the 
cause of the fatal termination of the complaint. 

As we treat of those subjects only as connected with the urethra, we may observe, 
that sometimes the urethra takes a course not round behind the os pubis simply, 
nor straight upwards, but curved backwards, so that the convexity of the catheter 
requires to be towards the sacrum, to allow the point to pass over the orifice of the 
womb, or perhaps the flexible, or the male catheter, may be required. 

The effect of the wedging of the child's head in a tedious labor, is to elongate 
and compress the urethra in a very particular manner. Many young men 



52 THE URETHRA. 

have felt the difficulty of introducing the catheter in this case. But it is a 
difficulty proceeding generally from ignorance or inattention. I believe there never 
occurs a case in which the child's head is so firmly impacted, that the catheter 
cannot be passed. But often practitioners forget the direction which the urethra 
necessarily assumes, when the child's head has sunk into the pelvis. 

Orificium Vagina. — This is also named Orificium. Externum, in distinction 
to the uterine orifice. I notice it under the head of the external parts, because we 
have to speak of the parts which surround the orifice, as the hymen. 

All anterior or external to the orifice of the vagina and within the labia is the ves- 
tibulum. The orifice of the vagina of the human female is abridged by the hymen, 
which is a peculiar membrane. It is of a semi-lunar form, and sometimes surrounds 
the lower part of the orifice of the vagina ; commonly it surrounds only the lower 
half of the circle, though it would seem to vary considerably in shape, place, and 
strength. It has been found surrounding the whole circle of the orifice, leaving 
only a small hole in the centre or upper part ; or it is described as perforated with 
lesser holes, allowing the evacuation of the menstrual blood. In other cases it has 
been found a complete septum, preventing the evacuations of the menstrual blood. 

This is a fact which I do not dispute, for I know that the perforation for the 
evacuation of the menstrual blood is sometimes necessary. When I have seen 
the imperforate vagina in the child, it was not the hymen which closed the orifice, 
but an adhesion of its sides ; yet this adhesion, if it had come to be distended 
with the menstrual blood of several periods would have presented the appearance of 
a tense membrane stretched across the orifice. 

Such semi-lunar membrane as I have described, will occasionally be seen in the 
female parts ; but it has such an appearance as may easily be destroyed in the 
preparation of the parts, if the anatomist be inattentive or careless. It is neither a 
guard, nor is its existence a test of female chastity. Often in tender children there 
is no such thing to be seen : while on the other hand, it has been cut to admit of 
labor and delivery.* Either of these facts is sufficient proof of the idle notions 
entertained concerning this membrane, and that when present it is like a contracted 
prseputium in the other sex, a defect. 

* I need not say now unnecessary and improper such operations are. All rigidity, callosities, even 
tumors, and undoubtedly the hymen, will yield to that general relaxation of all the parts, which takes 
place upon the commencement of labor. 






THE BLADDEH OF URINE. 5*5 

The Carungula Myktykokmks are small irregular tumors at the back or lower 
part of the external orifice: they are seated rather at the sides than exactly at the 
hack part; they are supposed to be the ruins of the hymen, which being lacerated, 
shrinks into two or three tumors on each side. Some have said, that these exist 
originally joined together, by a thin membrane, or delicate tissue of small vessels, 
the rupture of which causes an effusion of blood. They seem to be simply cor- 
rugations of the inner membrane, which serve as a provision for the dilatation of 
the parts ; and they accordingly disappear during the passage of the child's head. 

The Fossa Navicularis is a sinus supposed to be of the shape of a boat 
whence its name. It is formed betwixt the proper orifice of the vagina and the 
fourchette, or joining of the labia at their lower edge. It is more conspicuous in 
young subjects. 

From the meeting of the labia below, the Perineum commences ; it includes the 
space from the frsenum to the anus. 



PARTS CONTAINED WITHIN THE FEMALE PELVIS. 

These parts are the bladder of the urine, the vagina, the womb, the ovaria. We 
shall consider them under distinct sections. 

THE BLADDER OF URINE. 

As the coats of the bladder of urine in women do not vary from those of the 
male bladder, we have under this head only to notice the peculiarities in its rela- 
tive situation. It is seated behind the os pubis, and betwixt it and the womb ; 
and on its lower part it is attached to the vagina ; upon the neck of the bladder, or 
the beginning of the urethra, there is not a body like the prostate gland : and as we 
have seen, the urethra is short, wide, and straight, and simple in its use. 

Women are not subject to calculi, and the operation for the stone is rare in them ; 
for, as already observed, when the nucleus is formed, or when a stone slips down 
from the pelvis of the kidney, it passes from the bladder with much greater facility 
than in the male parts. The urethra of itself has been known to dilate so as to 



54 THE VAGINA; ITS SHAPE, CONNEXIONS, ETC. 

allow very large stones to pass, or it has been artificially dilated. Indeed the old 
operation for lithotomy was rudely to dilate, or rather tear, the urethra, and the 
modern operation is simply to thrust the gorget along the grooved staff, so as to 
lay open the side of the urethra and neck of the bladder, by an incision above the 
vagina. Sometimes nature has effected her own relief by the stone working 
from the neck of the bladder into the vagina. A woman had for a very long 
period suffered great distress, not only frequent desire to make urine, and the 
urine turbid and bloody, but all the usual symptoms of stone violently aggra- 
vated ; she was delicate and timid, and concealed her distress, until the urine had 
run for some time by the vagina. After she had been exhausted by long suffering, 
her friends insisted that she should allow an examination, when a stone was found 
partly in the bladder, with one of the rough ends projecting into the vagina. The 
opening was enlarged, and the stone extracted. 

We must, in all cases, recollect the connexion of the upper part of the vagina and 
orifice of the womb, with the back part of the bladder. We have seen its effects 
in producing retroversio uteri. We must also attend to this connexion, as tending 
to the displacement of the bladder in the procidentia uteri. The uterus sinking 
into the vagina, and the upper part of the vagina being at the same time reflected 
into the lower part, pulls down the bladder with it, and when (the disease increas- 
ing) the womb, covered by the vagina, comes to hang from the external parts, it 
has happened that the bladder has sunk down and lain upon the fore part of the 
tumor, but of course within the everted vagina. 

THE VAGINA *, ITS SHAPE, CONNEXIONS, ETC. 

The vagina is a tube stretching from the external orifice to the orifice of the 
womb. Its orifice is bounded below by the fourchette ; above by the arch of the 
pubis ; and directly over it, or sometimes within it, is the orifice of the urethra ; 
below, are the carunculee myrtiformes. It is surrounded by fasciculi of fibres, which 
are called the sphincter muscle. The canal of the vagina is of a conical form. 
At the outer orifice it is constricted by the sphincter muscle : but it is wider within, 
where it receives the orifice of the womb. It may be distended to almost any 
degree ; but naturally its sides, by their own elasticity, the fulness of the veins 
which are upon it, and the contraction of the surrounding fibres, are in contact. 



THE VAGINA; ITS SHAPE, CONNEXIONS, ETC. 55 

In the natural state, the orifices of the vagina and womb are but three or four 
inches distant, often only two ; and sometimes where there is a degree of relaxation, 
they are nearly in contact. In the first months of pregnancy, the orifice of the 
womb is kept down by the degree of difficulty the body of the womb has in shoot- 
ing up from the brim of the pelvis. But the gravid uterus rising above the pelvis 
in the latter months, draws up the orifice of the womb and stretches the vagina. 

The vagina bends gently round the pubis, or follows the axis of the pelvis ; and 
as the interior of two circles cut off by the same radii is the shorter, the vagina is 
longer behind than before. 

The vagina takes its curve nearly in the centre of the pelvis ; it is of necessity 
attached by cellular substance to the rectum and bladder. The urethra, as we have 
said, opens above the orifice, and that canal is attached to the vagina in its whole 
length, the neck of the bladder being attached to its upper part. In consequence of 
this natural connexion, disease of the vagina sometimes throws the whole parts, the 
rectum, vagina, and bladder, into one fistulous ulcer. 

The vagina has three coats ; that is to say, it has the inner coat, a few muscular 
fibres dispersed around it, and exteriorly a condensation of the surrounding cellular 
membrane, which may be considered as the third coat. 

The internal or villous coat, is a reflection of the delicate covering of the external 
parts. It is of larger extent, or longer than the others ; and is therefore tucked 
up into ruga?, which run across the vagina. They are more remarkable on the fore 
and back part of the vagina ; they are less in married women, and considerably 
obliterated by repeated labors. 

To supply a viscous secretion for the defence of this surface, there are mucous 
glands irregularly scattered over it, and they are particularly numerous at the 
orifice. 

The muscular coat is not very strong, nor are the fibres distinct, from which some 
have doubted their existence, alleging, that there is here only condensed cellular 
membrane ; and that the contraction of the vagina, is the effect of mere elasticity. 

I observe so great a profusion of venous vascularity, that I presume the vagina 
suffers an inflation of its coats, and consequently contraction from an afflux of blood 
to it. The muscular fibres are, however, as we have said, gathered into fasciculi 
near the orifice, so as to be distinctly visible. 



56 THE UTERUS. 

The firmness and structure of the vagina supports the womb ; the dilatation of 
the vagina, the relaxation which old age, and frequent labors produce, occasion the 
fallino- down of the womb. It is a disease almost peculiar to those who have borne 
many children, to the old, weak, and relaxed, and to "those who are subject to the 
fluor albus : every flux from the womb or discharge from the vagina, having a re- 
markable effect in relaxing the parts. 

This, from the nature of the parts, must be an increasing disease ; for no sooner 
has the womb fallen down into- the vagina, than it becomes a source of irritation, 
excites a bearing-down pain like tenesmus, an uneasy sensation, a desire to make 
urine, and an obstruction of urine : all which is explained by the connexion of the 
parts. The womb lodging in the vagina dilates the orifice, and presses long on the 
pefinseum ; at last it is entirely forced out, and the prolapsus uteri becomes the proci- 
dentia uteri ; it is in truth a hernia of the womb. 

The third and outer coat, as we have said, is formed of the cellular membrane, 
by which it is connected with the surrounding parts ; but the peritoneum comes 
down upon the higher part of the vagina. This is the reason why a portion of the 
intestine, when it slips down betwixt the vagina and rectum forms a kind of hernial 
tumor in the vagina, and it explains how the water of the ascites has pushed down 
the back of the vagina, so as to be felt externally ; indeed, the water of dropsy has 
been drawn off by puncturing here. 

For the greater space, however, the outer cellular coat of the vagina connects it 
with the urethra on the fore part, and with the rectum behind. From which close 
connexion of parts, we see the consequence of the delay of the child's head in the 
second stage of labor, that the head lies violently distending and compressing the 
parts, while the woman, exhausted by the previous stage, is unable to complete the 
delivery. From violent inflammation, with a deficiency of secretion, there arises a 
cold and flabby state of the parts. When the woman is delivered, the parts have 
suffered so much, that they slough off: sometimes the urethra is laid open on the 
fore part, and sometimes the rectum behind. 

THE UTERUS. 

The uterus or womb, is a firm vascular body of the size of a pear, and in shape 
not unlike what you may conceive of a flattened pear. At its upper and lateral 



THK UTERUS. 



57 



parts it terminates in the Fallopian tubes : and the os tinea;, or lower part, projects 
into the vagina. We must, for the convenience of description, distinguish it into 
these parts : — The upper p:irt is called fundus ; it is the part above the going off 
of the Fallopian tubes : the body of the uterus, which is the larger part betwixt 
the fundus and the narrow neck ; the cervix is the narrow neck ; and the os TINCJ3 
or orifice is the lower part, formed of bilging lips, wYieh projest into the vagina : 
over this part the inner membrane of the vagina is reflected. We distinguish also 
the two surfaces, for the womb is of a flattened form. The anterior surface of 
the body of the womb is convex, bat the posterior surface is considerably more 
convex than the anterior, and even during gestation it keeps this relative figure. 



19 11 1 7 11 




EXPLANATION OF PLATE. 



The Ureters, Fallopian tubes, the Ovaria, and a fart of the Vagina, of a Female of sixteen years. 
On one side the tube and ovary is divided vertically ; the othzr side is untouched. The Anterior 
Portion of the Uterus and P ugma have also been removed. 



1. Fundus of the uterus. 2. Thickness of its parietes anteriorly. 3. External surface of the 
Uterus: 4. Section of the neck of the uterus. 5. Section of the anterior lip. 6. Its posterior lip 
untouched. 7. Cavity of the uterus. 8. Cavity of its neck. 9. Thickness of the walls of the vagina. 
10. Its cavity and posterior parietes. 11. Openings of fallopian tubes into the uterus. 12. Cavity 
ofthelefc tube. 13. Its pavilion. 14. Corpus nmbriaturn. 15. Its union with the ovary. 16. Left 
r uy vertically divided. 17. Vesicles in its tissue. IS. Ligament of the ovary. 19 Right fallopian 
tube untouched. 20. Its corpus fimbriatum. 21. Right ovary. 22. Broad Ligament. 

The whole size of the uterus is about three inches in length, and two in breadth, 
but there is a very great variety in this respect, from age, the effect of pregnancies, 
and other causes. When, in its usual situations and relations, the fundus is on a 
level with the brim of the pelvis, or a very little below it. In the foetus, the womb 
is, like the bladder, considerably above the brim of the pelvis ; but in a few weeks 



58 THE UTERUS. 

the pelvis enlarging, it sinks deeper and soon assumes the same situation as in 
the adult. 

Fallopian Tubes. — From the lateral obtuse angles formed betwixt the fundus 
and the body of the uterus, the Fallopian tubes are continued. These tubes may 
almost be considered as a continuation of the uterus, did not we find them so very 
distinct in their substance. They are about three inches in length, take a tortuous 
course, and their extremities have an unequal fringed termination, which is called 
fimbriae.* Their canal is very small towards the uterus, but enlarges ; and is 
open towards the extremity. These canals are the communications by which the 
ovum formed in the ovarium is carried down into the womb. 

Ligament of the Uterus. — The uses ascribed to the ligaments have been to 
support the uterus from sinking too deep in the pelvis, and to steady it, and direct it 
in its ascent during pregnancy. But whatever good they may do in the latter ope- 
ration, they are certainly unfit for the former. 

There are four ligaments of the uterus. 

The Broad Ligament of the uterus is formed of the peritoneum ; for this mem- 
brane passing down before the rectum, and ascending again, and covering the neck, 
body, and fundus of the womb, descends on the fore part, so as to reach the vagina 
before it rises over the bladder. Thus it invests the womb as it does the abdomi- 
nal viscera. This investing of the womb with the peritoneum is indeed a provision 
for its becoming an abdominal viscus, for in pregnancy it .rises out of the pelvis, and 
being distended before the bowels, assumes in every respect that relation to the peri- 
toneum which they have. 

As the womb is included betwixt the duplicature of the peritoneum, it is this peri- 
toneal coat which is continued off laterally, and forms the broad ligament of the 
womb. This duplicature of the peritoneum, forming a fine membrane, has some- 
times had the name of alje vespertilonis. -.-at-is in truth like a mesentery to the 
womb and Fallopian tubes, and serves equally to support and convey the vessels to 
them. The womb and these two ligaments make a complete partition running 
across the pelvis. 

From the side of the uterus, a little below, and before the going off of the Fallo- 
pian tubes, the Round Ligaments arise. They are not merely condensed and 

*Morsus diaboli. 



THE UTERUS. 59 

elastic cellular membrane : bnl are composed of fibres with an intermixture of blood- 
vessels, so that whilst they keep a degree of tension on the uterus, they yield and 
grow not only in length, hut in thickness and strength, as the uterus ascends in 
advanced pregnancy : they pass through the abdominal ring, and are attached to the 
cellular membrane of the top of the thigh. In the gravid uterus, both the broad and 
the round ligaments considerably alter their position, appearing to rise lower, and more 
forward from the womb than in the unimpregnated state. This is a consequence of the 
greater increase of the fundus of the womb, in proportion to the lower part of it. 

What I have here described, and which are commonly called the round ligaments 
of the uteras, are the tendons of the muscles, and have a very particular use which 
authors have not observed ; at their upper extremity they terminate in a muscular 
coat which is spread over the fundus of the uterus diverging from the tendon. The 
use of these tendons is to move the uterus in the first approach of labor, and to 
present the orifice of the uterus to the axis of the pelvis. 

The triangular cavity of the uterus is lined with a peculiar soft and delicate mem- 
brane ; it is very vascular, and the vessels either open on the surface naturally, or 
bursting out from time to time, pour out the menstrual blood. The canal of the 
cervix shows a very different surface. We observe a prominent longitudinal line on 
the fore and back part of it, from which oblique and transverse rugae go out. The 
surface is firmer and callous, and less vascular. Betwixt the rugae there are lacunae, 
which throw out a mucilaginous fluid ; and towards the orifice we see these larger 
and sometimes distinct glandular bodies. This peculiar shape of the cavity of the 
womb, and the hardness and small degree of vascularity of the lower part is of the 
most essential importance. The upper part, the proper cavity of the womb, is pre- 
pared for the reception and immediate adhesion of the ovum, when it shall have 
descended through the Fallopian tube ; but the long callous cervix is provided, that 
there may be no adhesion to the lower part of the womb, and that the placenta may 
not form over the orifice of the womb, for if it should, the most dangerous kind of 
flooding takes place on the approach of labor, from the opening of the orifice, and 
the tearing open of the adhesions of the placenta, before the child can be delivered. 
The length of the cervix, and the glandular structure of the orifice, are also of much 
importance in sealing up the cavity of the womb after conception, that there may be 
no longer communication with the vagina : for this purpose, a viscid tenacious 
mucus is poured out ; but, on the approach of labor with the softening and relaxa- 



60 THE BLOOD-VESSELS OF THE WOMB. 

tion of all the soft parts, this adhesion and gluing up of the orifice is dissolved, and 
a more fluid secretion is poured out. 

From the cavity of the womb the Menstrual Blood is discharged at certain 
periods, from the time of puberty to the approach of old age, when the system is no 
longer capable of giving nourishment to the foetus. 

It was long disputed from what source the menstrual discharge flowed. Some 
affirmed that it must flow from the vagina, and not from the womb, because it flowed 
sometimes during gestation. This is a fact which cannot be denied. I have 
attended a patient who menstruated during the entire period, or to the eighth month; 
and I have often observed ladies to menstruate at the first period after conception. 
On the other hand, we have every proof of the discharge being from the orifice of 
the womb. For instance, some have observed on dissection of the parts of women 
dying during the flow of menses, that blood was effused under the delicate mem- 
brane of the cavity of the womb. The vessels there have been observed particularly 
turgid, or the whole surface of the proper cavity, and especially the fundus, spotted 
with bloody effusions. More particular observation has shown not only the mark of 
blood poured out from the inner surface, but that the whole substance of the womb 
was become thick, soft and vascular ;* and M. Littre affirms that in the body of 
a woman who had died during menstruation, and with a conception in the Fallopian 
tube, he found in the womb a layer of red coagulated blood ; upon removing which 
he saw a number of small foramina which admitted bristles.f 

But the best and least equivocal proof is that which has been repeatedly observed 
in the inversion of the womb, when the inner surface has been turned out after 
labor, and has remained thus inverted, and protruding from the external parts, for 
then the menstrual blood has been seen to distil from the surface of the cavity of 
the uterus. 

THE BLOOD-VESSELS OF THE WOMB. 

There are four large arteries which supply the system of the womb, and four 
large veins which return the blood. 

* The authorities upon this subject are Spigelius, Morgagni, M. Littre, Moriceau, Winslow, 
Sympson. 

t This might have been an early abortion, or perhaps the decidua, which it is said is sometimes 
formed at the menstrual period. 



THE BLOOD VESSELS OF THE WOMB. 61 

The Spermatic Arteries come down from the aorta itself, or from the renal 
or capsule arteries. The spermatic artery taking a waving direction, becomes 
tortuous in a most remarkable degree, as it approaches the uterus; it is distributed 
to the Fallopian tube, the ovarium, but chiefly to the body and fundus of the uterus, 
where it forms remarkable anastomoses with the artery of the other side. 

The Lower Artery — the Uterine Artery, comes in general from the hypo- 
gastric- artery, takes also a serpentine course, and is distributed to the vagina, and 
the lower part of the uterus, and inosculates largely with the other vessels, both in 
the uterus, and by particular branches on the side of the uterus. 

In the first place, it appears that this copious supply of vessels to the uterus, from 
four different sources, is a provision that the womb and secundines shall not by any 
accident of position, or by the progress of labor and the consequent compression of 
one or both the lower vessels, be deprived of their due supply of blood. Again, 
their tortuous forms give proof of their occasional greater activity, that they admit of 
a peculiar and local action during menstruation, and that the blood will move more 
languidly when the stimulus of the wound has ceased. It is also a provision for the 
growth and increase of the womb, and the supply of nourishment to the ovum. 
And that an increased activity in a part must be supplied by a more tortuous form, 
as well as an enlargement of the calibre of the vessels, is in a particular manner 
illustrated by the change which takes place in these vessels during pregnancy ; for 
they become in a much more remarkable degree tortuous and enlarged. 

The substance of the uterus is said to be spongy and compact, which, though it 
is a seeming contradiction in words, does yet really convey an idea of the effects of 
the intertexture of vessels in it. Some have said (as Moriceau), that by pregnancy 
the womb is distended, and grows thinner ; others that it grows thicker, as Daven- 
ter ; and others again, as Smellie, assert that it continues of its natural thickness. 
These assertions are none of them perfectly correct; for the womb is not distended 
by the growth of the foetus and membranes but grows with them. Again, that the 
substance of the womb grows in a remarkable degree is true, but still when dis- 
tended by the waters in the last month of pregnancy, its walls are thinner than in 
the unimpregnated state. Thus, when it has been cut in the living body, upon the 
approach of labor, as in the Csesarean section, I have observed it not more than a 
quarter of an inch in thickness, even at the part to which the placenta adhered. 

When I have dissected the womb after a tedious labour, the waters discharged, 



62 THE OVARIA. 

but the head wedged in the pelvis, I have found it considerably thicker. And, 
lastly, in the full contraction of the womb, after expelling the foetus and placenta, 
(for example, in rupture of the womb, where the child and placenta had been forced 
amono-st the bowels, and the woman soon after died,) I found the walls of the 
womb more than an inch in thickness. 



THE OVARIA. 

The Ovarta, are two oval bodies which are suspended in the broad ligament 
behind, and a little below the Fallopian tubes : while they have an Oval figure, they 
are, at the same time, somewhat flattened. But cutting out the ovaria, the animal 
loses the power of conceiving, and desire is extinguished ; they, therefore, bestow 
what is essential to generation upon the part of the female. In vague speculations 
on the subject of generation, they were supposed to prepare a female semen ! but 
more particular examination demonstrates that they consist of vesicles which are ova; 
but how far incomplete, or in what essential circumstance requiring the approach of 
the male is not determined. 

When we hold the section of the ovarium betwixt the eye and the light, we see a 
great many pellucid vesicles ; and if we examine the ovarium of an animal killed in 
full health, and particularly in the season, we shall observe these ova to be in all 
varieties of states of preparation for impregnation. Some small and pellucid, and 
yet only discernible in the thick outer coat, by having a degree of greater transpa- 
rency : others which have taken a slight tinge of bloody color from vessels striking 
into them ; and if the section be made after a minute injection, the vesicles will be 
seen colored in proportion of their maturity ; some without a speck of color : others 

tinged : one or two loaded with injection ; and some vascular, and particularly 

< 

prominent. 

In very young girls, the substance of the ovarium is whitish, and very soft ; the 
surrounding membrane is thick : and the round corpuscles scarcely discernible ; and 
no irregularities, nor any of those bodies called corpora lutea, are to be seen on the 
surface. But as the girl advances in years, the little vesicles begin to appear, and 
when about ten years of age, or just before menstruation, the ovarium is full of ova 
of various sizes, and some of them more matured, and forming an eminence upon 
the surface. In the adult woman, the substance of the ovarium which appeared as 



THE OVARIA. 63 

an uniform homogeneous mass in the foetus, is become a cellular and vascular bed, 
giving nourishment to those numerous vesicles or ova. Before impregnation can 
take place, there must be a certain state of preparation of the ovaria, without which 
the approach of the male effects no change in the uterine system. The lower ani- 
, mals having their seasons, and these seasons being a state of preparation for the 
male, impregnation follows the copulation with much certainty ; in women such 
a periodical revolution in their system, and instinctive desires, would but ill accord 
with that superiority in attributes of the mind, which distinguish us in the scale of 
beings. But women also suffer such an occasional excitement in the uterine 
system, though unaccompanied with desire, which preserves the womb in a state 
of preparation for the reception of the ovum, and the ovaria in a state of preparation 
for impregnation. This is the effect of menstruation. 



VENEKEAL DISEASES. 



CHAPTER III. 

INTRODUCTORY REMARKS. 

Venereal Diseases defined.; — Why is man afflicted with them 1 — They are not to he considered as 
punishments for sin. — When and where did the syphilis originate 1 — Its modem origin. — Its first 
appearance in Europe. — Its frightful effects in Otaheite. — Nature of the syphilitic virus. — Its 
chemical properties. — Gonorrhceal virus. — Its action supposed, formely, to he identical with that of 
syphilis. — Syphilitic chancre and hubo. — Constitutional effects. — Secondary symfttoms. — Govern- 
ment action necessary to extinguish these diseases. 

Before entering upon the particular description and treatment of venereal diseases, 
you will wish to know something of their nature and history.* Since when, and 
why has humanity been thus afflicted 1 Such questions are natural. But it is not 
easy in all cases to answer them. It is the melancholy province of science, too 
often, to point out the extent of our ignorance, and to discover the barriers beyond 
which investigation and reason can never pass. 

Venereal diseases, in the widest sense of the words, are those which arise from 
or are incident to the sexual connexion. In a more restricted sense, this term is 
applied to the two forms, syphilis and gonorrhoea, which are produced by the con- 
tact of two distinct poisons, or two species of venereal virus. 

If you ask why man alone, of all the animal creation is thus afflicted — is thus 
subject to the effects of this contagion — I am without an answer. The human 
race increases and multiplies in the same way as the higher orders of animals ; yet, 
in man, a virus is developed and communicated, which produces disease and death, 
in its most repulsive forms. That which produces the whole train of syphilitic 
symptoms upon man, produces no effect upon other animals. 

It may be stated in explanation of the personal style of this work, that, originally, it was prepared 
as a course of lectures. 



INTRODUCTORY REMARKS. 65 

You may ask a bolder question : Why is man afflicted with this disease at all — 
why, in the gratification of his most powerful and necessary instinct, is he liable to be 
inoculated with a terrible poison, which may affect him and his posterity 1 Science 
does not answer such questions. You may as well ask, why the plague ; why the 
small pox ; why the hundreds of diseases which afflict our species? They who are 
anxious to " vindicate the ways of God to man," will answer, that all diseases 
proceed from the violation of some natural law. 

To the inconsiderate, this answer, may seem sufficient : but it will scarcely 
account for the ravages of the plague which for so many centuries swept over 
Europe ; for the appearance of the small pox, which apparently took its place, and 
so long desolated nations, until a preventive was discovered in inoculation with the 
vaccine vims. Tt will scarcely account for the appearance of the Asiatic cholera, and 
its terrible and mournful march around the world. We cannot even give a reason- 
able answer to the question, why man should be liable to die of the slightest taint 
of the virus of hydrophobia 1 What law has he violated, or what sin committed 1 
The most innocent child may be most liable to suffer. 

It has been affirmed that the Creator has inflicted this disease, as the penalty of 
transgression. It is not without good reason that we must combat views like these. 
The same might be said of other diseases, and might be a ground for denying them 
proper treatment. Were such the fact, it would have existed in all countries and all 
ages ; it would fall only, or most heavily, upon the most guilty. Such is not the 
case : and we must look upon syphilis, and upon the whole class of venereal 
diseases, as accidents to which humanity is subject, and which it is our duty to 
prevent if possible, to relieve, and to cure. 

Let me be understood. These diseases are not, I say, inflicted as punishments 
for individual transgression. Is it the fault of the innocent babe, that it is born with 
an opthalmia, caught of its mother, at the very moment of its entrance into the 
world 1 Is it the fault of the infant, that its blood is poisoned in the first moment of 
its foetal life, and that its future existence is burdened with the most painful and 
revolting diseases ? Is it the fault of the pure and chaste woman, who contracts a 
venereal disease from her husband, who comes to her loving embraces, reeking 
from a brothel, and infects her, and his offspring, while he escapes the contagion 1 — 
for all this is possible ! 

No, gentlemen, we must give up, as false and unphilanthropic, the idea that these 



66 INTRODUCTORY REMARKS. 

diseases are intended as the punishment of individual guiltiness. We must look 
upon them as misfortunes, and not as the consequences of crime. I have found in 
my'practice that it is not the confirmed rake, or the hardened debauchee, who is 
affected with venereal diseases. They use caution — they avail themselves of pre- 
ventive measures, or at the worst, they apply immediately to the physician and are 
cured in the outset. It is the comparatively innocent and unsophisticated, who are 
the most likely to contract disease, and in whom its worst effects are developed. It 
is even true, as I shall have occasion to repeat hereafter, that one may become 
hardened against at least one form of venereal disease, so that the same cause 
which would affect others, will have upon him no effect whatever. 

If we are at a loss for any reasonable or proper answer, to the natural question, 
why was man made liable to venereal diseases, it is not much less difficult to answer 
the questions which follow, the " when V 3 and " where V 

There is reason to suppose that the milder form of venereal infection, the strictly 
local disease of the urethra, and other mucous surfaces, may have existed, with some 
modifications from time immemorial. It is undoubtedly true that leprosy was most 
commonly communicated by sexual intercourse, and that some other affections of 
the genital organs may have been, under certain circumstances, contagious : but it is 
as certain that the disease now called syphilis, produced by a specific virus, and 
developed in the chancre, bubo, and the secondary and tertiary symptoms, is of 
modern origin, in the civilized world, as any fact can be, which is not mathemati- 
cally demonstrable. 

Dr. Adam Clarke, a theological writer, and author of a commentary upon the 
Bible, having assumed that syphilis was a punishment inflicted upon man, for adul- 
terous sexual intercourse, endeavors to show that Moses alludes to this disease ; but 
his theory is unsupported by the words of the Hebrew lawgiver. "A running 
issue," or a voiding of " the seed of copulation," though a cause of ceremonial un- 
cleanness, according to the Mosaic law, will not answer as descriptions of this terrible 
disease ; and we cannot but smile when we see a respectable physician quoting one 
of the Psalms of David, to prove that the monarch of Israel, the man after God's 
own heart, was affected with the syphilis, caught from his wife, the mother of Solo- 
mon, from whom, according to the new testament genealogy, was descended Christ. 
Yet this is the strongest argument for the ancient existence of syphilis, gravely put 
forth in a work recently published in the city of New- York ! 



INTRODUCTORY REMARKS. 67 

Had syphilis existed in the early ages of the world, as the same specific disease 
it has been for the last three centuries, it would have; depopulated whole nations. 
Fire and brimstone, need not have rained upon Sodom aud Gomorrah. We know 
that promiscuous sexual intercourse and prostitution existed not only among the 
Jews, but to a far greater extent among the surrounding nations. They revelled in 
luxury and lust. Greece was famous for the number of her courtezans, as well as 
their beauty and accomplishments ; the people of Corinth offered prayers in the 
temple of Venus, that she would increase their numbers, so advantageous were they 
thought to the prosperity of the city. In certain islands, every woman was a pros- 
titute, and to orfer themselves to all strangers was considered as one of the sacred 
rites of hospitality. 

Greece, had her historians, poets, lawgivers, find physicians, whose writings have 
come down to us, and yet, neither in history, nor poem, in comedy or satire, nor yet 
in her works on medicine, or laws, in which all subjects are discussed with the 
utmost freedom, do we find any mention, or indication of the existence of such a 
disease. No, Greece, the land of beauty and of voluptuousness was free from this 
curse of the modern world. 

If this disease were the product of licentiousness, where should we expect to find 
it developed, if not in the capital of the Roman Empire, where every species of vice 
and immorality reigned triumphant, when whole cities lay sweltering in the vilest 
debauchery, in the days of the Neros, and Caligulas, and Messalinas 1 Hercula- 
neum and Pompeii were overwhelmed by the ashes and lava of Vesuvius. They now 
open to us proofs of inconceivable obscenity and profligacy ; but we find no where the 
slightest evidence of the existence of this disease. On the contrary, Celsus, the 
Roman, though he describes particularly eight varieties of ulcers which appeared 
upon the organs of generation, no where makes any allusion to a disease like our 
modern syphilis. Had the rakes or the prostitutes of Rome been subject to such a 
disease, had they suffered its horrors and deformities, would the fact have escaped 
the pens of such writers as Horace, and Juvenal, and Ovid ? 

The proof, though of a negative character, is overwhelming, and must convince 
every one, that so far as this disease is concerned, those were the golden ages of the 
world. We must be satisfied, that if this disease were intended as the punishment 
of promiscuous sexual intercourse, it had not then been inflicted upon mankind. 
When and where then did it originate ? 



68 INTRODUCTORY REMARKS. 

Syphilis appeared in Europe in 1493, just after the discoveiy of America by 
Columbus. In one of the vessels of the fleets which followed him to the West 
Indies, and returned to Spain, there were two hundred men affected with this disease. 
With incredible rapidity it spread over Spain — it was carried to France, and broke 
out in the army at the siege of Naples, in 1495 ; from the sea-ports and capital of 
Spain, from Paris, and from the army of Charles VIII., this disease spread fast over 
Europe. In France, it was called the Spanish Pox ; in England, it was known as 
the French Pox, or, as the doctors termed it, Morbus Gallicus. Its ravages were 
terrible. It seemed to spread itself every where, like the plague. Science was at 
fault, and this "new disease," as it was uniformly termed, was every where looked 
upon with terror. In the course of twenty years, a great number of treatises upon 
the disease were published, whereas none had ever before been written ; a sufficient 
proof, one would think, of the date of its appearance in Europe. In Madrid, the 
capital of Spain, nearly the whole population was affected with it, till in a few genera- 
tions the disease became in a manner constitutional in many families. A philoso- 
phical historian of the last century asserts, that from 1600, to 1700, one half the men 
in all the armies of Europe were affected With syphilitic diseases. He who denies 
the conclusions, based upon historical facts like these, may as well, like Broussais, 
deny the existence of the disease altogether. 

How the virus came to be developed in the West India Islands, and as some have 
contended in other tropical climates, science can never unfold to us. If it were attri- 
butable to heat of climate, it should have existed always in the tropics, and in one 
hemisphere as well as the other. Some have imagined that it was the result of canni- 
balism, which existed among the savage Caribs. If so, it should have been found in 
the South Sea Islands, especially in New Zealand, where, however, it was unknown 
until introduced by European voyagers. One author has attributed the disease to 
an unnatural connexion between men and a tribe of monkeys — another asserts, that 
instead of being brought home by the followers of Columbus, it was the product of the 
copulation of a man with a diseased mare at the siege of Naples. Modem medical 
writers generally have some favorite hypothesis to support, and so give ridiculous 
opinions ; but all other writers, since the discovery of America, have consid- 
ered the introduction of the syphilitic disease, as a sad offset to that great 
achievement. 

But we have an instance of the recent introduction of this disease before our eyes, 



i\ i imdi 0TOR1 REM IRKS. 89 

which proves thai the virus is not spontaneously developed, as the result of promiscu- 
ous sexual intercourse. 

The Island o!' Tahiti, or Otaheile. the principal of the group of Society Islands, 

in Polynesia, when first discovered by Captain Cook, contained a population of two 

hundred thousand souls. These islanders, from their personal beauty, and the soft- 
ness of their manners, were considered as among the most interesting people of that 
portion of the globe. At the same time, they were so voluptuous in their habits, 
and so free and promiscuous in their amours, that the first French navigators who 
visited the Island, called it the modern Cytherea. Chastity was a thing unthought 
of. Hospitality required every islander to oner to the stranger, not only food and 
shelter, but his wife or his daughter. The aristocracy of the Island had formed an 
association, for the purpose of encouraging the promiscuous intercourse of the sexes. 
With all this, such a disease was never heard of, until introduced from one of the 
ships which first visited this group. It soon spread over the island, and through 
the whole population. This beautiful Island — this enchanting paradise of the 
southern seas, became one lazar-house of disease and death. Under its destroying 
influences the population has gradually diminished, so that there now exists but a 
miserable remnant of nine thousand people, and many of these are sickly and de- 
formed from the effects of this disease. They are wasting away. The fountains 
of life are drying up — the race is withering and dying ; and in a few years there will be 
scarcely a remnant preserved of the people of this once populous and happy Island. 
When the English missionaries first went to Tahiti, and told them that they had come 
to bring them joyful tidings of salvation, the chiefs cried out in the bitterness of their 
souls — " Lies ! lies ! you bring us death, we are all dying of your accursed diseases !" 

Here, then, is an instance, and it is very far from being a solitary one, which 
shows that syphilis is not the natural result of voluptuousness and promiscuous 
sexual intercourse ; and so far as we know any thing of its history, it has always 
been propagated by contagion. Where it first appeared, what causes produced the 
virus, and under what circumstances it was developed, must ever remain among the 
hidden mysteries which abound in pathological science. 

These questions, however curious or interesting, are less important than that 
which immediately suggests itself: What is the nature of the syphilitic virus? 
or of what are the poisons which produce the venereal diseases composed, and 
how do they produce their specific actions upon the system 1 Is their virus acid or 



70 INTRODUCTORY REMARKS. 

alkaline, solid or gaseous, animate or inanimate? Can chemistry analyze them? 
Can the microscope reveal them 1 

Chemistry has proved that the pus, containing the gonorrheal virus, as well as 
that which produces the syphilitic chancre, is alkaline. In this respect they do not 
differ, but the microscope shows in the latter the existence of animalculae. But this 
is no proof that the poison is an alkali, or that the syphilitic virus is nothing but a 
description of microscopic existences, which copulate and breed. As these animal- 
culae are only found in syphilitic sores, in certain situations, we must consider them 
as accidental, or, at least, as having no necessary connexion with this virus — much 
less constituting its poisonous influence. 

Thus we are thrown back upon all that is left for us — to study the cause, through 
the effects it produces. And this is no novelty. In advancing beyond what are 
called the certain sciences, this is all that is left to us, unless it be the blindest, the 
most absurd, and the most useless theorizing. We come therefore, to the effects 
produced by the venereal poisons. 

The venereal virus, which produces the local affections, usually, though not in 
strict propriety, termed gonorrhoea, varies much in its action. Sometimes its first 
effects are observed within twenty-four hours after exposure — sometimes not for 
several weeks. In most cases, the period is from five to fifteen days. The first 
symptoms are a slight redness at the extremity of the urethra, an uneasy tickling 
sensation, something like that produced by a cold upon the other mucous surfaces, 
a smarting or burning in urinating, followed by a flow of mucus which gradually 
thickens into a yellowish and greenish puriform secretion. In some cases these 
symptoms are preceded by a heavy and uneasy sensation in the loins, and by a 
sense of drowsiness. 

The pus secreted by the mucous surface of the urethra, contains the virus, which 
is capable of producing a similar affection on other mucous surfaces, as the inside of 
the eye-lids, the lining membrane of the nose and mouth, and of the anus. In 
the female this affection may exist in the urethra, or vagina, or both. In males it 
does not usually extend in its first stage, more than an inch and a half beyond the 
opening of the urethra ; though the inflammation with which it is sometimes connected 
involves, at times, the glans penis, the testicles, and the bladder, and a kind of bubo, 
or enlargement of the neighboring glands, is not the unfrequent result. 

The most serious results of this affection are strictures, and a gleet, sometimes diffi- 



INTRODUCTORY i.' i : m \i;ks. 71 

cult of cure. The gonorrhcaa! virus never produces any of the symptoms oc conaeqnea- 

ees of the Syphilitic affection ; though both diseases may exist at the same time, and 

ma\ be confounded together. A more particular description of this species of vene- 
real affection, with its treatment, will be given in future lectures. 

In the whole history ol* medical science, there is no more extraordinary fact, than 
that the comparatively simple and local affection of gonorrhcaa, should have been con- 
sidered the same disease as the dreaded and terrible syphilis, and the product of 
the same virus. There is but one way of accounting for this strange mistake. 
Chancres, the product of the first action of the syphilitic virus, may exist in the 
urethra, and by their irritation produce an apparent gonorrhoea. The surgeon, mis- 
taking this for a real gonorrhoea, finds it followed by a true syphilitic bubo, or, in due 
time, by secondary syphilis, and all the symptoms of the disease we shall now 
briefly describe. 

When a person has been exposed to infection by sexual intercourse, and the virus 
is caught upon an eroded, tender and delicate surface, usually the glans penis, the 
prepuce, or just within the lips of the urethra, in the male, or the labia pudenda, 
vagina, or os uteri of the female, the surface thus affected becomes slightly inflamed 
in about twenty-four hours ; on the second or third day there is a slight tumefaction ; 
about the fourth day there appears a small pustule ; on the fifth day there commen- 
ces an elastic induration; after the sixth the pustule shrivels into a crust, or a series 
of layers, shaped like a truncated cone, with a depressed apex. Under these crusts is 
found an ulcer with a hardened base, a foul red surface, and a red, dark, or livid 
elevated margin. The pustule does not exist, without an epidermis ; but this is the 
general character of syphilitic chancre, more fully to be described hereafter. During 
the formation and indolent stage of the chancre, which may exist for an indefinite 
period, and which has sometimes lasted from one to two years, the virus is capable 
of reproducing the disease, by contact or inoculation. 

During the progress and continuance of the syphilitic chancre, the venereal poison 
appears to be produced and absorbed into the system, producing as the next most 
common symptom, an enlargement of the glands, termed buboes. These, when 
caused by the absorption of the virus, and having suppurated and opened, form 
deep-seated syphilitic ulcers, producing the virus capable of communicating the dis- 
ease by inoculation. 

This is the most ordinary method of producing primary syphilis, but it is evident 



72 INTRODUCTORY REMARKS. 

that the virus, wherever applied, will cause, under certain circumstances, its specific 
effects : thus, the lips, the tongue, the eye-lids, the nipple, or any tender or eroded 
spot upon the body, may be the seat of the chancre. 

The virus, having thus incubated, bred, or fermented, as some of the old school 
will have it, if the primitive sore is not cured within a certain period, stated by some 
writers at five days, or if the poison is not met and neutralized by antidotes, becomes 
absorbed, and enters into the circulation, producing after a time the train of secon- 
dary symptoms, the dreaded lues venerea of the old medical writers. 

The first breaking out of secondary or constitutional syphilis, may take place in 
ten days, or it may not appear for months, or even years, depending apparently upon 
the temperament of the patient. It is usually characterized by ulceration of the 
fauces, destruction of the uvula, and the spongy-bones of the nose, purple eruptions 
upon the breast, extensive ulcerations over the shoulder blade, on the elbow, and 
other surfaces lying near the bones, nodes upon the superficial bones, mucous tuber- 
cles, and a great variety of diseases of the skin. 

The syphilitic virus contained in secondary ulcers, will not produce the primitive 
affection, or chancre, by inoculation, but it may be transmitted from parent to child, 
from husband to wife, and perhaps also, from the infant to the nurse, and from the 
nurse to other infants. This poison may lie dormant in the system for months, or 
even years, or, without appearing in the individual, may be the curse of his or her 
posterity. 

Should the disease not be checked in the early period of what are termed the 
secondary symptoms, it marches on to its horrible close. The testicles swell and 
harden, excrescences appear about the anus, the hair falls from the head, the eyes are 
blinded, the ears deafened. The bones swell, exfoliate, and rot away in deep seated 
ulcerations ;► the bones of the face are destroyed, the skull becomes eaten in holes 
like a honey comb, or falls away from the brain, and finally the patient dies the most 
horrible and disgusting of deaths. 

Such are some of the symptoms, and such the usual progress of this disease ; to 
combat which, successfully, must be considered as one of the grandest triumphs of 
medical science, and surgical skill ; and prevention and eradication of which from 
the family of man, is a desideratum — an object to which physicians, magistrates and 
philanthropists should direct their efforts. In some of the countries of Europe, the 
attention of governments has long been directed to this subject. They have thought 



INTRODUCTORY REMARKS 73 

thai sound constitutions, and the public health were worth preserving. They use 
preventive measures, and enforce Banitary regulations with all the power of an armed 
police. The evil is thus greatly lessened, if not entirely prevented. 

On the other hand, England, and the United States following her example, have 
allowed these diseases to take their course, and lefl their people to Buffer such con- 
sequences as we Bee all around us. There is no sound philosophy, no true policy, 
DO justice — certainly no philanthropy in such a course ; and the medical profession 
is most of all in fault. There exists a deplorable degree of ignorance in regard to 
the nature and treatment of this whole class of diseases. Our hospitals, and our 
grave yards are fall of the monuments of ignorance in the regular medical profession, 
and quackery out of it ; and it requires bold and truly scientific and philanthropic 
physicians, to make this department of medicine a speciality, and to give it the rank 
and respectability which its importance merits. 

Without encumbering this lecture with quotations or annotations I lay down the 
following principles : * 

1st. That the two venereal diseases, gonorrhoea, and syphilis, are each produced 
by its own specific virus. 

2d. So far as we can judge, gonorrhoea may have existed from time immemorial, 
while syphilis is of comparatively modern date, and was never known in Europe 
until near the end of the fifteenth century. 

3d. Neither of these diseases are necessarily connected with practices of licentious- 
-. nor are they by any natural law the result of the promiscuous intercourse of 
the sexes ; and they are to be treated as accidents or misfortunes, rather than 
punishments. 

4th. Primary syphilis, as developed in the chancre, and bubo, proved syphilitic 
by inoculation, can only propagate this form of the disease ; but secondary symptoms 
may infect with a vims capable of producing the secondary disease, as in hereditary 
infection, and other cases, more fully to be set forth hereafter. 

I shall now proceed to the particular description and treatment of syphilitic 
disease in all its stages and complications. 



PLATE II. 

PRIMITIVE ULCERS BEGINNING WITH PUSTULES 
REGULAR INOCULATION. 



Fovk years ago, this patient, who is twenty-six years of age, contracted, for the first time, 
a gonorrhoea. The running was inconsiderable, and disappeared, in eight days, without 
treatment. 

The present affection, which the patient perceived four days after an impure connexion, 
is of two and a half months' standing. It began with severe itching ; afterwards, three 
pustules appeared on the inferior part of the prepuce, following the- course of artificial inocu- 
lation, and after their rupture, three primitive ulcers were readily observed. 

For a month, the patient treated himself at home with sarsaparilla wine, and mercurial 
ointment. So far from improving, the ulcerations made a marked progress; and soon, 
further behind, on the sheath, other similar chancres showed themselves. At the same time 
inflammatory symptoms presented themselves, and the patient came to us for treatment on 
the thirty-first of January. 

At this date, the parts affected are red and much inflamed. There is an incomplete 
phymosis, which, notwithstanding the aedema, permits the gland to be examined, and in 
which is seen, near the frenum, some ulcers with a yellowish-gray base, offering all the 
characters of the period of progress. The ulcerations on the limb of the prepuce, the first 
seat of the disease, show already, at their circumference, a whitish ring, an indication of 
the commencement of the period of reparation. Finally, on the skin of the penis, in con- 
sequence of the inflammation, which is accompanied with an erysipelatous swelling, the fol- 
licular ulcers, that commenced with pustules, are complicated with partial gangrene. In 
the right groin, a slight ganglionic tumefaction is perceptible, and pressure occasions quite 
a lively pain. 

The sores were washed with a concentrated solution of opium, and dressed with lint 
wetted with the same liquid. Diluted drinks and low diet. 

February 4th. There is less inflammation on the side of the genital organs, and the glans 
may be uncovered with considerable facility. The ganglionic tension of the right groin, 
has yielded to repose and general antiphlogistics. The use of opiates is continued ; drink 
of dog-grass and liquorice ; and soups and broths given. 

February 6th. The inflammation of the genital organs diminishes more and more, and 
there is but little tumefaction. Continue the opiates. The patient is put upon a quarter of 
an allowance of food. 

74 




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l : x i*i. a nation of PLATI ii. 75 

February 10th. The ulcerations present ■ good appearance. The superficial sloughs 
produced by mortification, in the puatnlea of the follicular inoculations of the skin of 
the penis, arc everywhere detached. Cauterization with the nitrate of silver, and the ap- 
plication of lint soaked with aromatic wine, is used over the whole. The diet increased 

to halt" allowance. 

February 14th. Nearly everywhere the period of reparation advances or is well es- 
tablished. On the prepuce tin- l>asc of the ulcers shows slight induration. Calomel oint- 
ment applied to this point. Every where else, continue the dressings with the aromatic 
wine, and cauterization with the nitrate of silver. 

February L8th. Cicatrization continues. The ulceration on the gland is healed. 

February 83d« The patient is obliged to leave on business. On the 25th he returned. 

The base of the chancres on the prepuce is still indurated, and the cicatrization is not 
complete. Continue the dressing with the calomel ointment, and add to the treatment one 
pill a day of iodide of mercury, with syrup and ptisan sudorifics. 

February 2Sth. Cicatrization is everywhere completed. Same general treatment 
continued. 

March 4th. The induration on the prepuce has disappeared. The treatment was con- 
tinued for a month afterwards. 



EXPLANATION OF PLATE II. 

Figure 1. The genital organs with a front view. On the edge of pre] ice, thickened and 
folded, are ulcers showing the first stages of the disease. Their centrt present the true 
character of the ulceration, whilst a whitish ring at the circumference indicates the com- 
mencement of reparation. Further behind is a gangrenous eschar, resulting from the morti- 
fication which has smitten the pustule of a follicular chancre. Still further behind is an 
entire pustule, the summit of which exhibits a brownish slough. The anterior half of the 
penis is erysipelatous, the intensity of which is not remarkable in that part of the prepuce 
which projects in front of the glans. 

Figure 2. The genital organs disposed in such a manner as to present the face of the 
follicular chancres in the pustulous stage, and the loose end of the prepuce before the glans. 
Near the edge is a black eschar, following the mortification of a pustule ; laterally, a folli- 
cular inoculation, two days old. Lower down is the face of a large pustule with a gangre- 
nous top, drawn on the first figure. Finally, on the limits of the inflamed parts, is another 
follicular chancre, which has caused a notable rising of the skin. 

Figure 3. A regular pustule, resulting from an inoculation with the lancet on the first of 
February ; the drawing was made on the third at nine o'clock in the morning. At the cir- 
cumference there is a slight thickening of the skin, the intensity of which diminishes, 
gradually, from the centre, in the same proportion as the red color of the inflammatory areola. 

Figure 4. Design taken on the fourth of February, at nine o'clock in the morning. The 
regular progress in the elements of the pustule. 



76 EXPLANATION OF PLATE II. 

Figure 5. Design taken on the fifth of February at nine o'clock in the morning. The 
same regular progress. In the centre is still seen traces of the point, pricked by the lancet. 
The epidermis is much raised by the pus. 

Figure 6. Drawn the sixth of February at ten o'clock in the morning. The development 
of the pustule is very considerable, owing to the rising of the epidermis, which is distended 
by a very great quantity of pus. 

Figure 7. Drawn on the seventh of February at ten o'clock in the morning. The same 
general progress ; the pustule, protected by a watch glass is not yet broken at any point. 

Figure 8. Drawn on the seventh of February at eleven o'clock in the morning. The 
pustule is ruptured, and the base presents, in the centre, an ulcer with, well defined edges. 
Beyond the ulceration, the portion of the skin denuded by the loss of the epedermis is red 
and superficially ulcerated, while the central ulcer is of a grayish color. 



CHAPTER IV. 
PRIM \ll\ SYPHILIS. — PROPHYLCATICS. 

Tin disease only to be ell'ectually prevented by the public authorities. — What some European nations 
have done. — England and the United States have done nothing. — Ko antidote has been discovered 
which can prevent its derelopement. — General suggestions to avoid infection. — Government regula- 
tions to protect the public against other contagious diseases. — Neglect of this disease. — The medi- 
cal profession should earnestly take up the subject. 

The first object of medical science should be to prevent disease; the second, to 
euro it : but we too often fail in both. 

Whatever disease is worth curing is worth preventing. If it be right to treat 
syphilis at all, it is right to prevent it, if we have the power. 

I trust that the time is past forever, when it was thought that venereal diseases, 
being punishments, inflicted by Providence for certain offences, ought not to be pre- 
vented. Common sense and common humanity alike revolt against such an idea. 

If the liability to this disease was any check upon licentiousness we should find 
vice existing less in our large cities than in the country, where the liability is less. 
The contrary is pretty generally thought to be the case. 

A frightful poison exists, and is spread through the community, producing the most 
terrible ravages. One would suppose that the very first question asked by any man 
of sense would be — how can its effects be prevented? Such a question should 
occupy the attention of scientific men, of philanthropists, of magistrates and 
legislators. 

We have our quarantine laws enforced rigidly and at a great expense, to guard us 
against the plague, the yellow fever, and the small pox. To more effectually prevent 
the latter disease, we have vaccination, and rewards and honors have been heaped 
upon its fortunate discoverer. Yet, we have not used the simplest means to prevent 
the spread of a disease which may compare with either of those which we guard 
against with so much trouble. 

77 



78 PRIMARY SYPHILIS. — PROPHYLCATICS. 

This is not the case universally. In this respect, several European governments 
are far in advance of ours, in taking measures for the protection of their people. 

In France, Holland, Germany, and perhaps other continental nations, proslitutes 
and houses of prostitution are placed under the constant surveillance of the police. 
The women are required under pain of imprisonment, to be examined frequently, 
and every care, consistent with what is thought the necessary degree of personal 
freedom, is used to prevent the spread of the infection. These measures have 
effected much, and the results would be more beneficial, were they more universal. 

But while some European nations, as those we have mentioned, appear to have 
something like a proper regard for the health and lives of their people, others, in 
this particular, are utterly neglectful. England, a great commercial nation, is con- 
stantly engaged in spreading these diseases round the world ; and we are not far 
behind her, in this corrupting influence. 

It is my deliberate opinion that the communication of the syphilitic virus ought to 
be made in all countries one of the highest offences known to the law. Surely such 
a crime is worse than theft or burglary — and not far below murder, since it may be 
the means of destroying a whole generation. 

I am certain, that, should all other countries besides England and the United 
States, unite for the extermination of this disease, they would be perfectly right in 
subjecting every person visiting them, from these countries, to a proper examination, 
and if necessary to a rigid quarantine ! 

It is evident that nothing is needssary for the eradication of the syphilitic poison 
from the world but an energetic combination of all nations for that purpose, for a few 
generations ; and with this disease would disappear a vast quantity of the most loath- 
some and incurable of the diseases now found in every civilized community. No 
one can read without the heart-ache, the descriptions given by travellers of the pure 
health, sound constitutions and freedom from sickness and deformities which existed 
in the Islands of Polynesia, if he contrasts them with the wretched and miserable 
condition to which they were reduced in a few years by the introduction of syphilitic 
diseases by European voyagers. What more terrible misfortune could have befallen 
them, and what more heinous crime could have been committed, than the introduc- 
tion of such a curse among those simple hearted and much too hospitable Islanders ! 

The effort to discover some antidote to this poison, which should prevent contagion, 
was long frowned down by the community, from the idea already adverted to— that 



PRIMARY BYPHILIS. — PROPHYLCATICS. 79 

these diseases were intended to punish libertinism. The medical society of Paris, 
us long ago as L815, appointed a commission to investigate tho claims of Lnna 
Calderon, who asserted thai ho had found out a perfeel antidote. His experiments 
tried upon himself appear to justify his claims, but as they wen: not encouraged, or 
rather, as a storm of persecution was raised against him, he kept his preventive a 
Becret. Ricord supposes it to have been some kind of caustic soap, but I Bee no 
good reason for his opinion. It was, however, a local application, applied to the 
point of infection, ami with invariable results. 

I may assert that no chemical or medicinal agent is now known to the medical 
profession, which can be at all relied upon as a specific antidote to the primary symp- 
toms of syphilis. 

In the absence of the necessary police regulations, which the health of individuals 
and the welfare of society alike demand, the surgeon can only recommend certain 
precautions, which may ho of more or less beneiit ; and in regard to the moral 
question, he must ho content with a single quotation, "The whole need not a phy- 
sician, but they that are sick." Those who never go astray, need neither advice nor 
warning — yet, in regard to this disease how often is the innocent wife the victim of 
the guilty husband ; and sometimes the innocent husband is infected by the guilty 
wit' . 

Cleanliness, a frequent and thorough washing of the parts most liable to infection, 
and a frequent examination not only of the external parts but of the whole extent of 
the vagina and os uteri, with the speculum, are among the best preventives against 
infection. It must not be forgotten that the virus may be communicated by a 
female, where such precautions are not taken, though she may not herself become 
infected with disease. The soaps, and solutions of the chlorides of lime or soda are 
not supposed to act specifically as antidotes, though if of sufficient strength they may 
act chemically upon the matter which holds the virus. 

Xo suspicious connexion should be hazarded if any abrasion exists, for in such 
case, inoculation, supposing the presence of virus, is almost certain. I would re- 
commend the frequent washing of the male organs with astringent lotions for the 
purpose of tanning and hardening the parts, which I think may be a powerful means 
of prevention of the disease; but possibly by this means the pleasure of sexual inter- 
course might be in an equal degree diminished. 

The covering of the penis by an artificial sheath, is a disagreeable measure, and 



80 PRIMARY SYPHILIS.— PROPHALCATICS. 

as Astruc has remarked, an illusive guarantee. It is liable to rupture, it is often 
pervious, and it does not protect all the parts exposed to infection. As a preventive 
to gonorrhoea, however, it may be considered effectual. 

The longer the contact the more is the exposure, and the moment after the con- 
summation of the act, the exposed parts should be washed with the greatest care, 
and any abrasion or lesion of continuity, should be immediately cauterized. 

The least of these preventive measures, unsatisfactory as they are, may not only 
save a valuable life, prevent domestic unhappiness, protect another generation from 
the inheritance of loathsome diseases, but it may assist in checking the dissemina- 
tion of the cause of all these evils. ' 

I might go beyond all these and exhort men to be chaste and virtuous ; but this is 
the office of the clergyman, and not of the physician. If an hundred pulpits thunder 
in vain against immorality — if hospitals crowded with disease, and the hourly ex- 
hibitions of deformity, are not enough to restrain men from vicious indulgence, my 
feeble voice would be raised in vain. Like the army surgeon, I can do nothing to 
prevent the fight, but it is none the less my duty to stand ready to give assistance 
where it is required. 

Since it appears then, that the resources of medicine are of so unsatisfactory a 
character in regard to the prevention of this class of diseases, it is the more neces- 
sary that government should exert its salutary functions, and that the community 
should have the power of the police, in enforcing the necessary regulations for pro- 
moting the public health. 

We have inspectors going round periodically, to take precautions against fires, but 
against this fire which burns men's souls out of their bodies with lingering tortures, 
no such precaution is taken. 

We have health inspectors, who go round inspecting yards and nozing out sinks 
from which there comes too strong an effluvium, but they pass by with neglect houses 
which spread around them the most pestilential diseases. 

There is not a reason in favor of our health and quarantine regulations, which does 
not apply in full force to the importance of using similar measures for the prevention 
of venereal diseases. 

Our police at the present time has an accurate registry of the houses of ill fame, 
and the number of inmates. Every woman of the town, her residence and connexions 
are known. To make the proper regulations in regard to the public health it is 



PRIM LB v SYPHILIS.— PROPHYLACTICS. 81 

Decessarj to go but one step more, and thai step would be a benefit to the city and 
to tin 1 human race, In lessening the aggregate amount of evil. 

v Btranger in the city Bometimea loses Ins watch or pocket book at what are called 
pannel houses. He goes to the police-office, the officers arc set on the track, the 
Offenders are arrested, and sometimes the property recovered, and the thieves sent to 
prison. But a countryman may he robbed of health, happiness, and life itself, with- 
out any such remedy, or any remedy other than a prompt application for medical 
advice, and then it is an even chance if he do not fall into the hands of quackery. 

The medical profession of the United States ought to come to the aid of the pub- 
lic authorities, and the New-York Academy of Medicine would do well to offer as a 
prize question, the same that was not long since offered by the Society of the Medi- 
cal Sciences, of Brussels, — namely: "What measures of medical police are best 
adapted to arrest the propagation of venereal diseases !" 



PLATE III. 

PRIMARY FOLLICULAR ULCER: VIRULENT BUBO 
REGULAR INOCULATION. 



On the ninth of January the patient had sexual intercourse, and three days after, he per- 
ceived the presence of a small ulceration, situated on the right side of the superior face of 
the glans. At this time he was suffering still from a gonorrhoea, which he had contracted 
on the twenty-sixth of December. The running had increased but little, notwithstanding 
he had neglected the regimen that we had directed ; and six days later, it had passed to 
almost the mucous state. T\yo days after the patient observed the chancre on the glans, he 
felt in the groin considerable pain, and a bubo developed itself with all the symptoms of an 
acute inflammation. Up to the 28th day of January, the day of first consulting us, he had 
undergone a general antiphlogistic treatment, and a rigid course of diet. 

To-day there still remains a slight urethral discharge. On the glans, an ulcer may be 
seen having a grayish base, with abrupt edges, and presenting all the characters of the fol- 
licular chancre. The red areola which surrounds it is but little extended, and appears 
nearly limited to that portion of the tissues, which, slightly raised, offer a little tension. 
Apart from this local symptom, the genital organs preserve their natural color, and present 
no sign of inflammation. 

In the fold of the groin, the seat of the bubo, the skin is thin, adherent, and of a lively 
red color. There is an evident fluctuation, and one can judge of the extent of the centre 
occupied by the pus, by the space comprised between the sides, which are neatly marked, 
and easily traced, in consequence of their notable resistance. 

On the 99th of January, the bubo is opened, and furnishes a considerable quantity of 
yellowish pus. The surface of the focus is covered with gray points. It shows a perfect 
resemblance to ulcers in the state of progress. The chancre on the glans appears stationary ; 
its base is at all times grayish. Inoculation is performed on the right thigh with the pus 
which it furnished. Cataplasms are applied to the bubo ; the chancre is dressed with 
cerate. One quarter allowance of food, with cooling drinks. 

January 30th. The pus of the bubo is inoculated in the left thigh. 

February 2d. The pustules from inoculation are well formed. Continue the same dress- 
ings and the same regimen. 

February 3d. The pustule on the right thigh is broken, and shows the characteristic 
ulcer produced by inoculation. Its base is grayish. In the centre is seen a grayish spot 
like that of the chancre on the glans. 

82 










Fia. 1. 




o 



1 






Fig;Z. 



Ftg.3. 



Fig.4- 



EXPLANATION OF PLATE ill 83 

Tin" opening of the bubo presents ulcerated sides ;i little turned outwards. The centre 
is in the stage of ulceration and progressi and the thin skin thai cover*; d is of ;i reddish- 
violet color. The neighboring ganglions are slightly inflamed] and hut little: sensible to 
pressure. 

The chancre on the glans is cauterized with the Vienna-Paste, confining it as much as 
possible to the limits of the ulcer. Continue the Bame treatment and the same regimen. 

r bruarj 4th. The cauterization applied to the chancre on tin- glans, has extended hut 
little beyond the ulceration. A small black eschar covers the pan. 

The ulcers on the two thighs, have made regular progress. They arc also cauterized 
with the Vienna-Paste. Half an allowance of food. Continue the poultices on the bubo, 

which suppurates abundantly. 

February 8th. The black eschar produced by the Vienna-Paste on the chancre of the 
glans. was detached during the night ; the bottom of the sore is of a lively red. This 
slate saems to indicate the destruction of the virulent principle The focus of the bubo is 
cauterized with the nitrate of silver, and dressed with lint saturated with aromatic wine. 
Same regimen. 

February 10th. The sore on the glans, resulting from cauterization is of a fine rose color. 
Dress it with aromatic wine. 

The sloughs caused by the Paste applied to the thigh on the 4th of February, fell off on 
the 15th. 

February loth. The sore of the glans is nearly cicatrized ; those on the thighs look rosy 
and healthy. Their virulent nature has been completely destroyed by the caustic. Dressed 
with the aromatic wine. For the bubo, the same dressing. Diet as before. 

February 20th. The sores from inoculation are everywhere cicatrized. The focus of the 
bubo diminishes, and there is much less suppuration. Same regimen and same dressing. 

March 2d. To obtain a granulation favorable to the production of skin with which to 
cover the focus of the bubo, the bottom of which gradually rises, the powder of cantharides 
is applied. 

March 10th. The reparation goes on well ; the sore in the groin is rosy, and covered with 
granulations of a healthy nature. 

March 20th. Left cured. Not the least induration can be perceived under the cicatrices 
of the ulcers, either on the glans or the thighs. It has not been necessary to have re- 
course to general treatment. 



EXPLANATION OF PLATE III. 

Figure 1. The genital organs are seen, as sketched on the third of February. On the 
glans may be observed an ulcer resulting from follicular inoculation, that took place during 
a sexual connexion in which the patient indulged on the ninth of January. Its edges are 
clearly defined, abrupt, and slightly turned outward. The bottom of the ulcer is grayish. 
In the fold of the groin the borders of the incision, made to open the focus of a virulent 



84 EXPLANATION OF PLATE 111. 

bubo, present the aspect of an inoculated wound. They have ulcerated, remain apart, 
and are turned a little outwards. On the inferior margin of the upper side, a portion of the 
tissue is seen invaded by ulceration. A drop of pus is escaping from the lower angle of 
the sore. 

Figure 2. Represents an ulcer produced on the right thigh by inoculation, done on the 
29th of January, with pus furnished by the chancre of the glans. The drawing of it was 
taken on the 3d of February, at 10 o'clock in the morning, immediately after having broken 
the pustule. 

Figure 3. Is the same ulcer, drawn on the 4th of February at 10 o'clock in the morning. 

Figure 4. This ulcer has resulted from the inoculation of matter taken from the ulcer in 
the groin. On the 30th of January the inoculation was made on the left thigh, and the 
drawing of it was taken on the 3d of February. 

The figure with the lips of the urethra separated, exhibits an ulcer on the inner surface, 
and shows how true syphilis and gonorrhoea came to be considered identical diseases. 




N 

* 




#- 
s 



PLATE IV. 

PRIMARY ULCERS: ACUTE BALANO-POSTHITIS: 
PHYMOSIS: GANGRENE. 



This patient, who has been accustomed to drink to excess, had never had any venereal 
affection, until, six days after a recent sexual intercourse, he experienced considerable smart- 
ing on the glans. When he examined the parts, there already existed swelling of the pre- 
puce and glans, and there were some very painful ulcers on the balano-mucous membrane. 
The patient consulted an empiric, who ordered dressings with a whitish powder, and ad- 
ministered a ptisan which greatly excited the secretion of urine. 

The swelling of the parts made rapid progress ; in the three anterior quarters, the penis 
was doubled in volume ; it was impossible to uncover the glans, and the pain soon became 
intolerable. From that time the patient ceased all treatment. 

He comes to us on the 19th of May. There exists a very intense phymosis ; the organ is 
three times the natural size, and the skin of the prepuce presents, on the right, a blackish 
semi-circular eschor. In all other places, the parts exhibit a reddish-brown color. The 
end of the prepuce is the seat of a considerable oedema, nevertheless the extremity of the 
glans can still be seen. In its inferior part, the prepuce shows quite a remarkable projec- 
tion, and forms, before the glans, a species of receptacle, filled with bloody pus, and gan- 
grenous detritus. The urethra, from which the urine readily flows, furnishes no morbid mat- 
ter; and the running, which escapes abundantly, proceeds entirely from the glans and 
prepuce. Erections give no pain in the urethra, and the extremity of the penis only is the 
of acute sufferings, occasioned by the pressure of the prepuce on the glans. It is also 
only at the ulcerated glans and prepuce that the patient feels smarting at the time of 
urinating. 

The inguinal regions, carefully examined, present no sign of ganglionic tumefaction, and 
pressure there reveals no abnormal sensibility; finally, the bloody matter, escaping from the 
ulcers, has caused an erythema, quite intense, on the part which it touches, and this state is 
above all remarkable at the genito-crural fold, on the scrotum, and on the internal face of 
the thighs. Although the patient feels the most acute pains, and for three days has suffered 
from an intense fever, he will not submit to a division of the prepuce. Apply thirty leeches 
to the groins. The penis is kept enveloped with compresses soaked with a concentrated 
solution of opium. Low diet directed ; sulphuric lemonade, opium and camphor pills. 

May 20th. Drawing made of the genital organs. There is less pain. Continue the 
dressings with the solution of opium. The same regimen. 

May 21st. The swelling has much diminished. The same dressing continued. 

85 



86 EXPLANATION OF PLATE IV. 

May 22d. The gangrenous parts are detached, and a sketch is taken of the organs in this 
state. There is now but little pain. At its superior part, the prepuce is quite regularly 
destroyed, following a line which corresponds to the projection of the base of the gland, 
whilst below, it forms an irregular shred, to which the eschar is still adherent. On the 
glans may be seen gangrenous detritus. All the balano-mucous membrane is destroyed, but 
the organ itself is not deeply affected. 

The emission of urine is always easy ; the fever has nearly subsided. Continue the 
opiates and the same regimen. 

May 23d. The gangrene has made no progress ; and, as far as possible, the still adhering 
sloughs are removed by artificial means. The same dressing and the same regimen. 

May 24th. The gangrenous matter has disappeared from nearly every part, and but little 
swelling remains. Pus was taken from the glans, and inoculated in the left thigh. The 
dressings of the solution of opium are used on every part. Diet of broths and soups. 

May 27th. The sores are rose-colored, and present in no part the appearance of chancres; 
there is no longer any swelling. The inoculation has produced nothing, and given thus the 
certainty that the gangrene has radically modified the specific nature of the primitive ulcers. 
It is of equal importance to notice that the pus, mixed with the gangrenous detritus — the 
contact of which was sufficient to develope on the skin in the vicinity of the diseased parts, 
the erythema of which we have spoken — has not furnished, by inoculation, the least symp- 
tom that it was possible to confound with those which result from the inoculation of pus 
containing the syphilitic virus — an agent indispensible to obtain the regular phenomena that 
accompany its introduction under the epidermis, and which cannot be replaced by secre- 
tions, more or less acrid, that the genitals can supply, whatever be the degree of inflamma- 
tion of the ulcers that are situated upon them. 

Dress with aromatic wine, and give one quarter of an allowance of food. 

May 28th. The remaining piece of prepuce was excised, in order to make regular the 
circumcision effected by gangrene. The same dressing. Give half an allowance of food. 

May 29th. Cauterized with the nitrate of silver some fleshy granulations on the edge of 
the prepuce. 

June 1st. The cicatrization of the glans is complete, as also that of the superior part of 
the prepuce. Touched lightly with the nitrate of silver the parts not cicatrized. 

June 9th. The patient left perfectly cured. 



EXPLANATION OF PLATE IV. 

Figure 1. View of the Genital Organs, drawn on the twentieth of May. The penis, in 
the three anterior quarters of its extent, is the seat of a very considerable swelling. On the 
right side of the prepuce may be observed the superior extremity of a gangrenous eschar, 
which follows a semi-circular direction, towards the inferior parts. The skin of the penis, 
elsewhere, is reddish-brown. At the superior part of the opening presented by the edge of 
the prepuce, will be noticed the extremity of the glans, and the meatus urinarius ; below, 



KXl'I.AN \TK)N OF PLATE IV- 87 

the detritus of gangrene and sanious pus till the Bpecies of pocket formed l>y the prolonga- 
tion of tlK 1 inferior lip of the prepuce. 

Figure 9. View of the Genital Organs in the same position as in the first figure; drawing 
made the twenty-second of May. The prepuce, smitten \^ith gangrene in three quarters of 
its extent, following the direction of the corona glandis, is detached in its superior parts, 
IS turned over, and adheres by an irregular slued at the bottom. On the ghms, the mucous 
membrane of which is entirely destroyed by gangrene, are portions of slough and traces of 
ulceration, superficially covering the body of the organ, at the anterior extremity of which 
may be distinguished the meatus urinarius. All the parts are bathed with reddish pus, sani- 
ous, and mixed with detritus of gangrene. 



CHAPTER V. 

PRIMARY SYPHILIS. — CHANCRE. 

Its definition. — Infallible test of its syphilitic character. — Different varieties. — Remarks upon its diag- 
nosis. — Time which may elapse between the infection and the appearance of the sore. — May 
sometimes be seen on the lips or tongue. — Prognosis; this is affected by the variety. — The com- 
. plications. — Bubos not a necessary result of chancre. — When does chancre cease to produce the 
specific virus 1 — The abortive treatment. — The kind of chancre influences the probability of secon- 
dary symptoms. — Local treatment: Excision; Caustic. — Constitutional treatment: Mercurials; Regi- 
men. — Circumstances modifying the treatment. — Chancres in the urethra ; in the vagina, and on the 
os uteri. — When cantharides may be useful. — Chancres accompanied with violent inflammation; 
with haemorrhages. 

The name of chancre has been given, by common consent, to the primary syphi- 
litic ulcer, which usually appears upon the glans penis, or prepuce, but may be 
developed upon any portion of the body, and upon such of the mucous tissues, as 
are not, by the abundance of their secretions, protected from the action of the virus. 

The syphilitic poison is generally received in sexual intercourse with a person 
who is diseased ; but this is not a necessary condition. So that the matter from a 
venereal sore be recent, it may be inoculated with a lancet, by the finger nail, as in 
scratching after dressing a venereal sore, by the contact of a pipe or drinking glass, 
possibly by a privy or bath, and it is not unfrequently communicated by either 
male or female, who is not affected with the disease. Thus a man, with the virus 
of a chancre, taken from a prostitue, concealed beneath his prepuce, may communi- 
cate the disease to his wife, without being himself diseased. The same result may 
be produced on the other side ; and the consequences are more easily imagined than 
described. 

But in whatever way the poison is applied, it is only by its application in some 
form or manner that chancre is ever produced ; and the matter from a chancre, 
taken at the proper time, and applied in the proper manner will always produce it. 
This rule, so far as I know, admits of no exceptions. It matters not that the 

88 



NUMAKS SYPHILIS. — CHANCRE. N 

patient has other chancres, that be is effected with gonorrhoea, that h<- has p o ena 
dary syphilis or any other disease, bo long as the matterof a p ro gr es sive or indolent 
chancre is applied to a surface not affected with an acnte inflammation, or not too 
copiously secreting, and introduced beneath tin- epidermis or epithelium, the result 
will be the formation of a true syphilitic affection, which in its turn will produce a 
third, and so on indefinitely. 

Here, then, is an infallible test of the true character of a suspicious ulcer; and, 
however difficull it may be, in some cases, to distinguish sores which are not viru- 
Itiit from those the consequences of which are always to be guarded against, inocu- 
lation is a sure guide to a correct diagnosis. 

This is a test, however, which patients are not always willing to submit to ; yet 
few intelligent persons would object, were the nature of the experiment properly ex- 
plained. I say — "Here is a pustule, or ulcer, as the case may be, in a suspicious^ 
situation, and the result of a suspicious connexion, perhaps : it is probably syphilitic, 
but possibly not. If it is not, it will do you no kind of harm for me to take some 
of its matter upon the point of my lancet, and prick the inside of your thigh. I 
shall treat the first sore as if it were a chancre, and if it prove to have been one, by 
the production of a second, I have but to remove that, in the same manner, and fol- 
low up their cure with such constitutional treatment, as may prevent the appearance 
of the dreaded secondary symptoms." Should nothing result from the inoculation, 
of course no preventive treatment would be necessary, and the patient, if he have 
the proper confidence in your skill, will be relieved from all apprehensjon. 

The beginning and progress of the chancre, the result of inoculation, or when- 
ever the virus by any means has found a lodgment beneath the epidermis or epithe- 
lium, has been described in the third chapter, but this is by no means the only form 
on which the chancre exhibits itself. A mucous or sebaceous follicle is the common 
seat of the disease ; often a scratch, an erosion, or an ulcer already existing, is the 
part infected. The matter may also be carried into a lymphatic vessel or gland, and 
there produce its specific result. Finally, it is maintained by some surgeons, that 
the virus, in a particular state of the absorbents, may be taken up and carried to 
the glands of the groin, producing bubo, or go directly into the system, when the first 
indication of the disease will be the development of secondary symptoms. 

When the virus penetrates a mucous or sebaceous follicle, whose orifice afterwards 
becomes obliterated, a small tubercular abscess is formed, which afterwards presents 



90 PRIMARY SYPHILIS. — CHANCRE. 

all the appearances of chancre ; and the same effect is produced in the sub-mucous 
or sub-cutaneous tissues ,when the poison is introduced by a leech-bite or such other 
means as will allow the edges of the wound to unite. In the lymphatics and glands, 
the result is a syphilitic ulcer. When the virus is applied to a denuded surface, 
there will be ulceration from the commencement. 

Chancres may exist in the urethra of the male, and in the vagina and uterus of 
the female, in which cases the outward symptoms are those of a gonorrhoea. When 
they are seated near the mouth of the urethra in the male, they may sometimes be 
discovered by pulling it open, as seen in Plate III. In the female they must be 
sought for with the speculum. These concealed chancres with gonorrhceal symp- 
toms, have given rise to the opinion that the diseases were identical. As in other 
cases, the test is inoculation. 
There exist, sometimes, chancres so superficial as not to destroy the entire thick- 
ness of the skin. These are not always attended with induration, and the raised 
margins correspond with the depth of ulceration. 

In general, the local progress of a chancre is soon limited by the deposition of 
plastic lymph, which forms the characteristic induration. But under certain consti- 
tutional or local circumstances, the ulceration goes on, and is then termed phagede- 
nic, and this kind may be of several varieties. 

One kind bears a resemblance to hospital gangrene, and spreads over the surface 
in a serpentine or ring-like manner. The depth of these sores bears no proportion 
to their surface — the parts are not much swollen, and there is none of the charac- 
teristic induration. This extensive superficial ulceration has been thought to be less 
frequently followed by secondary symptoms than other forms of the chancre ; but this 
result may have been the consequence of the treatment. It lasts, sometimes, 
more than a year. 

An excess of induration sometimes seems to destroy the part, and subjects it to 
an indolent, gangrenous affection, which, beginning at the surface, gradually in- 
creases in depth, unless the induration is destroyed. These gangrenous symptoms 
do not extend beyond the limits of the induration. 

A gangrene, accompanied with gray or black sloughing which destroys the chan- 
cre, is sometimes caused by inflammation. 

All these varieties may be complicated with each other; and the same chancre 
may, in its different parts, exhibit different appearances. 



PRIM \KY sv PHILIS.— CH INCRE. 91 

The different forma of chaacrea do not appear to be the result of any modifica- 
tions in the nature of the poison, bol rather to be caused l>y difference! in tempenv 

■ODtO, habits, ages, and conditions of individuals. 

\ i union may here be given iii regard to inoculation. A patient who has a pha- 
gedenic chancre on out- part will In- likely to have another us the result of inocula- 
tion, which accident, therefore, is to he avoided. 

It will have been seen that the diagnosis of chancre is not without its difficulties. 
There are. however, certain appearances which are seldom ahsent. The chancre 
usually begins with an itching in the part. If on the glans penis, a small pimple, full 
Of* matter, hut without much hardness or tumefaction, is developed. The itching 
gradually turns to pain, and the pimple is either excoriated or becomes the scab of 
an ulcer. The parts are affected with a circumscribed thickening, terminating ab- 
ruptly ; the base is hardened; the edges elevated, indurated, and often excavated. 

These characteristics, however, are not to be considered as absolute indications, 
on the one hand ; while, on the other, I have spoken of chancres which vary 
materially from this description. 

When a sore upon or about the organs of generation follows a suspicious sexual 
connexion, there is reason to suppose that it is syphilitic, and to treat it according- 
ly. It* it he followed by a bubo, and in due time, by secondary affections, of course 
there is no room to doubt ; but this kind of diagnosis is of little practical benefit. 
There however remains the nearly certain evidence afforded by inoculation, as 
proved in the experiments of Ricord, who has made Venereal Diseases a speciality, 
and to whom, for his researches in this branch of medicine and surgery, the whole 
world is indebted. 

We must not allow ourselves to be deceived by the protestations of our patients, 
or by appearances favorable to the purity of those with whom they have had connex- 
ion. In regard to such diseases, one would think that the consequences which may 
arise from deception would he sufficient to induce candor. This, however, is cer- 
tainly not always the case ; while the patient may be, and often is, himself, deceived. 
The surgeon, while obtaining "as correct information as possible from the patient, 
should still rely much more upon his own judgment. In delicate cases, he may 
properly conceal the real nature of the disease from the patient or others; or, where 
there are so many possibilities in regard to the mode in which it is contracted, he 
may take his choice as to the particular cause to which he attributes the disease. 



92 PRIMARY SYPHILIS. — CHANCRE. 

All this must be left to the conscience of the medical adviser, and the particular 
circumstances of the case. 

There is an important question as to the time which may elapse between the infection 
and the appearance of the chancre. It may come on within twenty-four hours, and 
there are authentic cases in which the virus has lain dormant, enclosed in a follicle 
perhaps, for eight or ten weeks, or even a longer period. It may also exist without 
the patient suspecting it. 

Besides the genital organs, and the parts immediately adjacent, chancres some- 
times occur upon the lips, and have even been detected upon the tongue and gums, 
caught in a manner, not very frequent perhaps, but still occasionally witnessed. M. 
Ricord gives three cases of undoubted chancre in the mouth, in one of which the 
patient was a poet of some celebrity, who avowed that in a moment of exaltation 
he had run the risk of direct contagion. Whether another term than exaltation 
might not have been used with more propriety, is, perhaps, a mere matter of taste. 
As, however, there are innocent means by which the syphilitic virus may be brought 
in contact with these parts, the patient had as well have the benefit of all such 
possibilities. 

The prognosis of chancre in its simplest form, and unattended with the aggrava- 
tions and complications above described, is regular and simple. In a good consti- 
tution, with temperate habits, it begins as a pustule, an abcess, or excoriation ; it 
becomes an ulcer ; its progress is stayed by ah extravasation of lymph ; it takes on 
the reparative stage ; granulations form, and cicatrization follows, without treatment, 
in from three to five weeks. This is the natural and regular course of the primary 
syphilitic ulcer. 

But, in a majority of cases, we must not look for results so favorable. Patients 
who are badly nourished, exposed to impure air, of dissipated habits, or, in short, of 
a debilitated or cachectic constitution, from whatever cause, are liable to have the cold, 
watery, and sloughing ulcer ; while patients of a veiy robust and plethoric system, 
and those addicted to stimulating drinks, are likely to have a complication of the 
sloughing ulcer, with gangrene. The indurated ulcer seems to depend upon no 
constitutional habit from which we can predict its appearance. 

In the most favorable situation, a simple chancre, under proper treatment, may be 
cured in eight or ten days. But when it is situated where a rupture of the cicatri- 
zation may occur every time the parts are disturbed, the progress of cure will be 






Fcff.t. 



Ftff:3. 



^^^ 




•F*.-4 



PLATE V. 

•RIMAR1 ULCERS OF THE MEATUS PRINARIUS AND PREPUCE: INFLAM- 
MATION OV A LYMPHATIC VESSEL: BUBO, FOLLOWED BY 
ULCERATION AND ACCIDENTAL INOCULATION. 



BLENORRHAGIA : PRIMARY ULCER OF THE MEATUS UR1NAR1US : SUP- 
PURATED LYMPHATIC VESSEL AND BUBO: ARTIFICIAL 
INOCULATION, WITH THE RESULT. 

FIRST CASE. 

This patient, the subject of the first figure, had never had a venereal affection, previous 
to the attack of the present. Taking little care to examine the state of his genital organs, 
he perceived nothing remarkable, during the first three or four days, save a slight itching 
about the penis. Gradually considerable pain was felt in urinating, and, soon afterwards, 
a discharge from the urethra occurred. The lips of the meatus were swollen, and on turn- 
ing them outward, a chancre in the urethra was discovered. 

A few days nfter the appearance of these symptoms, for which no treatment had been 
directed, the prepuce became red, cedematous, and a phymosis ensued, with the symptoms 
of an active intlainmation. Nearlv at the same time, ulcerations showed themselves on the 
prepuce, produced by the inoculation of matter, furnished by the primitive ulcer in the 
meatus urinarius. An apothecary being consulted, the patient received some kind of medi- 
cine, and was put upon a general antiphlogistic regimen. 

The fifteenth or twentieth day after the attack, lymphitis became apparent on the right 
side of the poni>, near the root of which, on the tract of the vessel, a small tumor formed, 
which soon fluctuated, and was opened spontaneously, uncovering a focus offering all the 
characters of a primitive ulcer. 

At the same time that the lymphatic inflammation showed itself, the glands of the right 
groin were becoming engorged. The bubo made rapid progress, and in ten to twelve day? 

93 



94 EXPLANATION OF PLATE V, 

after the commencement of the accident, it opened spontaneously, and discharged much 
sanious pus. Here, as in the ulceration of the lymphatic vessel, the skin was soon destroyed 
that covered the purulent centre. Finally, a short time after, in consequence of a custom 
that the patient had of leaving the penis, during the night, to repose on the right groin, the 
skin where the scrotum begins, which was thus brought in contact with the chancre of the 
lymphatic, became the seat of a similar ulceration. 

The disease making such progress, the patient lost all confidence that at first he had ac- 
corded to the treatment ordered by his apothecary; he ceased the use of remedies, and re- 
turned to his work again, which caused much irritation in the affected parts. 

The day that he came under regular treatment, we remarked on the patient an acciden- 
tal phymosis. The contracted prepuce formed in front of the glans a considerable projec- 
tion ; and that cedematous portion, turned back and outwards, allows us to perceive a 
primitive ulcer extending itself on all the right side of the prepuce. This ulcer, produced 
by the re-union of many ulcerations, originally separated and developed in the folds of the 
limb of the prepuce, has edges that are very irregularly cut ; the whole thickness of the 
mucous membrane is neatly removed, and the ulcerated surface is covered over by a false 
membrane, of a grayish color and adherent, which, in three fourths of its extent, presents 
very small red points very near to each other, and are produced by a sort of haemorrhagic 
transudation. 

On the sheath, near the root of the penis, the chancre resulting from the ulceration of the 
lymphatic, has all the characters of the period of progress ,* its surface is covered by a false 
adherent membrane, soft and grayish. 

Further behind, at the junction of the scrotum with the skin of the abdomen, the chan- 
cre, resulting from inoculation by contiguity, offers, in a smaller extent, the most perfect re- 
semblance to the ulcer that we have described, with this particular difference, that here the 
loosening of the skin is more considerable, and the pus, filtrating beneath, has formed 
in the cellular tissue a virulent abscess, of which we perceive the opening ulcerated and 
quite narrow, at the distance of about the third of an inch in the direction of the groin. 

In the right inguinal region, an ulceration, with edges abruptly cut, cedematous, slightly 
turned out, and surrounded with a violet-red colored areola, the extent of which cor- 
responds with much regularity to that of the undermining of the skin, marks the place 
of the suppurated bubo. Here, again, we find the characters of the period of progress. 
The bottom of the ulcer is not so gray as that of the last chancre that we descrihed, and 
shows itself under the influence of a species of haemorrhagic transudation, to a degree still 
more marked than in the ulcer of the limb of the prepuce. 

June 19th. Applied a cataplasm on the groin, and dressed the ulcerations with opium 
cerate. One fourth of full diet. 

June 24th. Under the influence of repose and of opium dressings, the ulcers seem less 
irritated. Same dressings continued. Give half an allowance of food. 

June 2Sth. There is now but little irritation, and the chancres of the different regions 
have a better aspect ; their side?; are less raised, and their bases appear to be cleaning in 
some points. Dressing and diet the same as before. 

July 6th. Suppuration is everywhere abundant, but the surface of the chancres is less 
grayish. Dressed with lint moistened with aromatic wine. Same regimen. 



i:\nw LTX>N 0» PLATE V. !•:» 

July I Oth. The surface of the ulcers continue to clean. There is an evident tendency 
to reparation. Cauteriie with the nitrate of silver. 

Julv 1 4th. The grayish bed which covers the surface of the ulcers, in Bome points ap- 
pears to persist. Suspend the dressings with the wine. The chancres are touched with i 
brush w.i with the tincture of pure iodine, and dressed with the tincture diluted. The diet 
is increased to three quarters of an allowanpe. 

July lTtli. In all parts there is a sensible amelioration, and the period of reparation is 
distinctly manifest : the surface of ih«' ulcers is covered with granulations of a good nature, 
and the extent of each is diminished one half. In the groin, above all, the reparation is re- 
markable, and not the least undermining is now seen. Dressing with aromatic wine. 

On the 24th of August, the different ulcerated points wore perfectly cicatrized and with- 
out induration. I'hyuiosis still continued, and it was removed by circumcision. It could 
now be seen that tin; lips of tin 1 meatus had been destroyed by a chancre, which, at this 
time, was cicatrized. 

September 14th. Well in all respects. 



SECOND CASE. 



Fob three months this patient has been affected with a blenorrbagia, occasioning but little 
severe pain. During the most acute period of the malady, erections, even, were not pain- 
ful ; and it was only in urinating that there was a slight burning towards the meatus. Ten 
to twelve days alter he presented himself, the discharge that the urethra furnished in but a 
small quantity, was white, and like the secretion of gonorrhoea. Twenty-five leeches were 
applied to the perineum. Two camphor pills were prescribed each night; cooling drinks, 
and abstinence from all exciting food. He afterwards took capsules of copaiba and cubebs, 
in the dose of twenty-five a day, when the running was nearly dried up, but still showing 
itself more or less, in direct proportion to the irritation which followed the sexual relations 
that the patient frequently allowed himself. This state lasted about a month and a half, 
when, after several days debauch, the discharge seemed notably increased, and some pains 
were fit at the meatus. These new symptoms have been remarked for the last twelve 
day-. Nearly at the same time, the inguinal glands of the right side became tender and 
swollen. 

Finally, on the tract of a lymphatic vessel, on the right side of the penis, two tumors are 
formed, that have increased with rapidity, presenting all the characters of very acute ab- 
scesses. The tumor which first showed itself, has its seat behind the base of the glans. 
At this time it offers, on it- anterior side, a grayish ulceration, cutting in a very regular 
manner through the thick integuments, and on the bottom of which, the pus of the abscess 



96 EXPLANATION OF PLATE V. 

is in part seen. The second tumor, in the vicinity of the root of the penis, is covered 
with a very thin skin, but presents no opening. 

The right inguinal region is the seat of a superficial bubo, circumscribed, very painful» 
and fluctuating; it developed itself at the same time as the tumor of which we have spoken, 
and its progress has been the same. 

September 25th. Besides the accidents already described, on turning back the prepuce a 
reddish areola is seen around the meatus, and on separating the lips of the opening, a small 
gray ulcer may be perceived, occupying the superior commissure, but it is impossible to 
know to what depth it extends, because of the narrowness of the parts. On pressing on 
the urethra from behind forwards, a small quantity of bloody sero-purulent matter is 
forced out. 

Pus collected at the meatus urinarius, has been inoculated on the left thigh. A drawing 
fs made of the parts. 

September 26th. The portion of ulcerated skin that covered the tumor at the base of 
the glans, was spontaneously detached during the night, and the purulent focus presents 
all the characters of a virulent ulceration in the period of progress. 

The abscess at the root of the penis is opened by a single puncture. Apply poultices. 
Give a quarter of an allowance of aliment. 

September 29th. The inoculation has furnished a pustule characteristic of primary syphi- 
litic ulcer. 

The lips of the meatus urinarius are separated, and the superior commissure is cauterized 
with the nitrate of silver. Dress with an ointment of calomel and opium. Half an allow- 
ance of food. 

September 30th. The ulcer on the thigh, resulting from the inoculation, is cauterized with 
the Vienna-paste. 

October 10th. Cauterizations with the nitrate of silver, and dressings with the aromatic 
wine, the employment of which was prescribed four days ago, has produced a remarkable 
amelioration. The ulcers are well cleaned, and their bottom has assumed a good aspect ; 
numerous rose-colored granulations have pierced the bed of gray that covered the surface. 
The portions of skin that the ulcei - ation has not destroyed, have contracted many points of 
adhesion with the subjacent tissues. Finally, the suppuration is less considerable, and the 
nature of the pus is of a better quality. We can perceive no longer the ulceration of the 
meatus, and the urethra furnishes no more pus. The ulceration of the thigh, cauterized by 
the Vienna-paste, is covered with a crust slightly depressed. Same dressing and regimen 
as before. 

October 15th. The ulcerations present in many points the characters of the period of repa- 
ration. The inoculation is perfectly cicatrized. Same dressing. Give three quarters of 
an allowance of food. 

October 20th. The whole of the bases of the ulcerations are rose-colored, and of a good 
nature ; the extent of their surface is diminished more than one half. Dressings and diet 
the same. 

October 25th. The ulcerations of the groin and that at the root of the penis are nearly 
cicatrized. Touch them lightly with caustic and dress them with dry lint. 

October 29th. All is cicatrized, and no part can be found indurated. Discharged. 



PL v\ \ riON OF PL \tk v. !ir 



EXPLANATION OF PLATE V. 

I :«'' I- The penis is turned on the lefl thigh, in such a way as to presenl a front view of 
the differeni ulcerated parts. 

The mucous membrane of the thickened prepuce is the seal of a considerable oedema 
and is turned backwards. On the righl side is an ulceration, with the margins irregularly 
cut out, and its surface is covered by a grayish matter. In the smallest part, the prepuce 
is strictured before the glans. Near the rout of the penis is an ulceration which is the result. 
ol the suppuration of a Lymphatic, the sides of which project and are undermined. Here 
the grayish false membrane covering the surface of the ulcer is thick and unequal. Behind 
this are two ulcerations caused by inoculation of the pus of the ulcer which we have just 
spoken of. The largest is the result of direct action, following the contacl of the parts; 
the other has been produced by filtration of the matter beneath the skin in the cellular 
tissue. 

The inguinal region presents an ulceration that has succeeded to a virulent bubo. On 
the side next to the thigh, the skin is -more undermined than in any other part. All around 
bluish color o[ the skin indicates the extent of the undermining. The surface of the 
ulcer is covered with an irregular false membrane, of the same nature as that of the other 
ulcerations, but having a reddish tint, proceeding from a kind of hemorrhagic transudation 
that we often sec in this species of ulceration. 

Figun 2. The extremity of the glar.s is covered by the prepuce, on the inferior lip of 
which is a drop of purulent matter that has escaped from the meatus urinarius. Behind 
the base of the -Inns is a tumor developed on the tract of a lymphatic: a part of the 
skin which covers it is ulcerated. Towards the root of the penis is a tumor like that already 
spoken of. It is fluctuating, and shows at its centre a portion of very thin skin, on which 
we can already remark the first degree of alteration that announces, often, spontaneous 
perforation. 

The rio;lit inguinal region presents a fluctuating tumor, which has followed the suppura- 
tion of superficial bubo. 

The rose-color of the integuments indicates the extent of the purulent deposit, and every- 
where the lluctuation is distinct. 



98 PRIMAK Y SYPHILIS. — CHANCRE. 

much, longer ; and other things being equal, a large chancre takes longer to heal 
than a small one ; though this rule seems to admit of exceptions, as sometimes 
several chancres of different sizes heal in the same time ; and it would also seem 
that several chancres will heal as quickly as if there were but one. 

The duration of the diptheritic chancre depends upon the constitution and the 
circumstances which affect it. 

The serpiginous or annular chancre, when apparently almost cured, may break 
out again with more violence than ever. 

The gangrenous sloughing chancre, though a horrible variety, is more easily con- 
trolled, and its speedy termination may be more confidently predicted. 

The indurated sore, left to itself, will remain for an indefinite period ; or if it 
heals, a swelling, like cartilage, will remain, which yields very slowly to general and 
local treatment. 

There are complications, liable to occur in two varieties of chancre, whichdem and 
the surgeon's most serious attention. In diptheritic chancre, haemorrhage, (where 
blood vessels are involved,) or fistula? are to be dreaded, according to the situation 
and tissues implicated ; while a large and rapid destruction of the parts often attend 
the gangrenous sloughing chancre. 

New ulcerations are liable to be produced wherever the virus comes in contact 
with a denuded, or tender, or pervious surface, and such an extension and continu- 
ance of the disease cannot be too carefully guarded against. 

Buboes are by no means a necessary result of chancres, and their occurrence 
seems to depend much upon the seat of the primitive sore. They have never been 
known to follow a chancre on the thigh, and are seldom the result of sores upon the 
prepuce, or the superior portion of the glans penis. According to the statistics of 
the Parisian hospitals, eighty cases out of one hundred were the result of chancres 
upon the frenum. Females are much less liable to bubo than males ; and, when it 
does appear in them, the chancre is usually found in the vicinity of the meatus 
urinarius. The anatomical reasons for bubo more frequently following chancres in 
these situations are sufficiently obvious. 

Though it is agreed that the chancre in its reparative stage no longer secretes or 
produces the specific virus, yet, as it is difficult to say precisely when that stage has 
fully taken place, and as one portion of a chancre may have healthy granulations, 
while in another and possibly a minute portion, the virus is still in action, sexual 



PRIM \i;y syphilis— CHANCRE 99 

connexion cannol be allowed with Bafety. There is another reason. A sore, about 
to heal, or which hasjnsl cicatrized, is liable to inflame and alcerate from new irrita- 
tion, and may, under these circumstances, take on the worst and tnosl dreaded 
forms <>\ the venerial nicer. No medical man can safely take the responsibilit) of 
allowing Bexnal intercourse, when snch a condition exists, with a proper regard to the 
safety of the patient, the party with whom intercourse is had, or their possible off- 
spring. There should he no donbl or hesitation in a matter so vitally important. 
In such a case. •• caution is the parent of safety." 

W e come now to the most important subject connected with the prognosis of 
chancre, in which it is to be considered with reference to the probability of general 
infection, or secondary symptoms. 

It : s the opinion of Itieord, that if the chancre is destroyed within the fifth clay 

from the period of infection, no secondary symptoms are to be apprehended. 

on, a pupil of Ricord, says, that when the chancre has proceeded beyond the 

vesicular form, seen on the third day, freedom from constitutional effects cannot be 

guarantied. 

My own opinion is, that no person is absolutely free from the risk of general con- 
tagion from the first moment that the virus acts upon an exposed surface, or can be 
in any manner absorbed into the system. I believe that not only is bubo or glan- 
dular chancre formed by the direct absorption of the virus, but that it maybe carried 
into the system without producing either chancre or bubo, and, after an indefinite 
period, produce the secondary symptoms. There are many cases in the books, and 
I have met with some in my own practice, which cannot be accounted for upon any 
other hypothesis. 

Besides this, it is rare that the surgeon can get at the precise period of infection ; 
and I am satisfied that the only safe course is to treat every case as if secondary 
iptoms were to be apprehended. 

\s chancre is the form in which syphilitic affections commonly begin, its proper 
treatment is an object of the first importance. 

When the disease is submitted to the physician or surgeon at a sufficiently early 
stage, the first treatment indicated is what is termed the abortive. The object is to 
check, in the most speedy and effectual manner, the formation of the syphilitic virus. 
This may be done either by excision, or by potential cauterization, or by both com- 
bined, which is a more thorough practice, and the one I have found effectual. 



100 PRIMARY SYPHILIS. — CHANCRE. 

The patient presents himself, with one or more pustules upon the glans penis, or 
a chancrous ulcer upon the prepuce. In the former case excision may be difficult. 
The common practice is to rupture the pustule with a lancet, and cauterize the ulcer 
with a pointed stick of the nitrate of silver. Should this not destroy the ulceration, 
the operation must be repeated. When the pustule or chancre is upon the pre- 
puce, if not too extensive, I prefer to raise it with a pair of delicate four-pronged 
forceps, and cut it completely away, cauterizing the wound afterwards, and in both 
cases I prefer the caustic potash to the nitrate of silver. They both act upon the 
same principle, but the one that does its work most thoroughly is to be preferred. 
And it may here be set down as a rule that any lesion or abrasion, after a suspicious 
intercourse, should be cauterized without hesitation, and without waiting to see what 
it will come to. 

It is true, however, that, without reference to the treatment, secondary symptoms 
do not follow every case of chancre, and that the longer the chancre continues, the 
more liable are they to follow. I would state the proposition differently ; I would say, 
that the smaller the quantity of virus absorbed, the more likely is it to be thrown off, 
or neutralized, and the more distant or less frequent would be the chances of a de- 
velopment of constitutional symptoms. 

The situation of chancres does not, as it does with bubo, make any apparent dif- 
ference in the frequency of the appearance of the secondary disease ; but in regard 
to the varieties, there is a remarkable difference. The serpiginous sore and the 
gangrenous ulcer are seldom followed by these symptoms — the phagedenic dip- 
theritic occasionally gives rise to them, and the indurated almost always. It was 
this fact which induced Mr. Hunter to believe, that the indurated base was an ab- 
solute syphilitic symptom, and that there were no others. In fact, a chancre with 
induration is almost certain to be followed by secondary symptoms unless active 
preventive treatment is resorted to ; and I cannot feel justified in neglecting such 
treatment in any case of syphilitic infection. The result has been that in an ex- 
tensive practice of many years, I have never had a case of secondary syphilis, in 
which the primary affection has been under my treatment in any of its early stages. 

It may be considered a disgrace to science, that no absolute antidote to this 
poison has ever been discovered — nothing that will at once meet the virus in the 
tissues that it has attacked, and neutralize its specific action. We are driven, there- 
fore, to excision and cauterization. 



PRIM im SYPHILIS. -CHANCRE. 101 

Excision is always to bo preferred, where the nature of the tissues will allow of 
'•• I o clip out a piece i>t" iho prepveo, oven if it be a pretty largo one, it of very 
little consequence ; l>nt upon, and behind the glnns, and especially on iho frennm, 
this cannot bo accomplished. Here the caustic mast be the romea'y. I have said 

thai I [)rcforred the caustic potash to the nitrate of silver. Some caution must be 

had in its use. It should bo applied with care, and in a good light ; and as it liqui- 
fies rapidly, a piece ot* lint must he at hand to wipe it off or absorb it immediately, 
when it overruns the prescribed boundaries* 

W \\c\[ the ulcer is spread over an abraded surface of some extent, the caustic may 
be pass -d lightly over the whole ulceration. In all cases, as seen ns the eschar 
comes off, it should be looked to; and unless healthy granulations are ; forming, it 

must receive a second cauterizuliun. 

When the chancre is not at once destroyed, the French surgeons highly recom- 
mend dressings of hut dipped in aromatic wine. If prepared of the light and highly 
astringent red wines, this may be a good dressing, but 1 have found other astringent 
decoctions or solutions answer equally as well. The object is to check secretion 
and harden the surrounding tissues, so as to prevent the spread of the sore. Fre- 
quent and careful dressings arc among the best anti syphilitics. Quiet, temperance, 
and a proper constitutional condition arc of course to be considered. 

Bui shall we stop with this local treatment, and be content with the extirpation or 
rapid cure of the chancre ? I have already given my reasons for pursuing a different 
course. I would never neglect local and constitutional preventive measures, as 
■ds against the progress of the disease, and the development of secondary symp- 
toms. Simultaneously with my first excision or cauterization of the incipient chan- 
cre, I take careful measures to check the advance of the enemy, in the direction of 
the groin. This I accomplish in the following manner: — I take two strips of ad- 
besive-plaster, each an inch in width, and about two inches in length. These are 
spread with Btrong mercurial ointment, leaving a sufficient margin to cause them to 
adhere. They arc then placed so that the two are made nearly to encircle the penis, 
one on cither side. Applied in this mode the unpleasant effects, which, during 
erections, would ensue, if but a single strip going completely around the organ was 
employed, are avoided. The plaster, of course, is applied between the chancre, and 
the groin. While using this remedy locally, I adminstcr internally, some one of the 
preparations of mercury — preferring, commonly, the proto-iodide, the blue-pill, or 
Plummcr's pill, until the gums are slightly affected. 



102 PRIMARY SYPHILIS. — CHANCRE. 

1 may not, indeed, be able to show the specific action of mercury upon the syphi- 
litic virus, but 1 have found this course of treatment a safe and effectual one ; and 
until some further discoveries are made in regard to this disease and its remedies, 
I shall persist in this course of treatment. Those who arc more afraid of the effects 
of mercury than the horrors of syphilis, will avoid the former — and risk, perhaps, 
the latter. 

It may be denied that mercury is a specific remedy for syphilis : but it is also 
denied, and by a very high authority, that syphilis is itself a specific disease. We 
may as well let one denial offset the other. In what manner mercury acts upon the 
venereal virus, I do not pretend to say, but that it does act as a preventive and cura- 
tive, there is no more doubt than of the existence of the disease. One supposition 
is, that it meets and neutralizes the poison, or uniies with it and carries it out of the 
system. Another notion is that mercury takes a forcible possession of the absor- 
bent and secretory organs, and drives everything else before it. Mr. Hunter's 
theory was that the tissues could not labor under two specific actions at the same 
time, and that the cure of the syphilitic action was the result of the mercurial. 

I shall not offer any theory upon the subject. I reget that a more absolute and 
certain specific has not been found for syphilis ; but since it is the best and the safest 
I know of, I use it accordingly. 

The action of mercury varies much in different constitutions. One patient may 
take large doses of blue-pill for weeks, without showing any symptoms of its action ; 
but, notwithstanding this, the disease is cured. In another, a few grains of calomel 
produces salivation ; while there are a few whose idiosyncrasies seem to forbid the 
use of mercury altogether. Prejudices may also oppose its administration ; but they 
who have exposed themselves to the action of the syphilitic poison, ought not to ob- 
ject to any other which may be necessary as an antidote. 

The use of mercurial ointment as a local application to chancres, or that of any 
greasy substances, is to be strictly proscribed. Simple poultices and fomentations, with 
the dressings of aromatic wine, and an aqueous solution of opium, when indicated 
by the pain ; the black and yellow wash, or a solution of bichloride of mercury, are 
the best local applications that can be used, except the cauterizations, as before 
mentioned. 

As the state of the system may influence the forms which chancres are liable to 
take on, this cannot be too soon attended to. A full habit, and excesses in eating 
or drinking, may produce violent inflammation, tending to gangrene. In such a 



/ 



PLATK VI. 



PRIMARY DLCEH ON THE NECK OF THE UTERUS. 

A r\n::\r applied tor advice who h:ul, on ihe left side of the anterior extremity of the 
gl ins, ;m ulceration offering nil ihe characteristics of chancre. Many questions were asked 
to ascertain the source of the infection, the reality of which was contested by the patient; 
for, he said that for a long time he had had sexual connexion with but one person, whom it 
was impossible to suspect, and who, besides, had been pronounced irreproachable, after an 
examination made minutely by a physician. Finally, an intimate friend of the patient, had, 
like him, had frequent sexual connexion with the woman, and yet his genital organs pre- 
sented no trace of infection. Notwithstanding the vnluc of such evidence to prove the 
health* of the lady, it was believed to be a dirty to neglect nothing for arriving at a convic- 
tion, and the woman presented herself, assured, said she, of her innocence, already es- 
tablished by n medical examination. 

The examination commenced with the external genitals; — the genito-crural fold, the 
labia mnjora and minora, the folds around the clitoris, the fourchette, the carunculse myrti- 
formes, and the infractuosities separating them, were separately and most carefully inspect- 
ed, an I n > suspicious appearance was io be found; there was no abrasion, nor any trace 
of morbid secretions; the meatus urinarius was healthy, and pressure made from behind 
forwards on th : urethra, with the aid of a linger introduced into the vagina, forced from the 
canal no abnormal discharge. The anus, likewise, showed all the characters of sound 
health. The speculum was applied, and the mucous membrane of the vagina, whether it 
examined in front, at the moment of unfolding itself before the advance of the ex- 
tremity of the instrument, or whether seen obliquely between its valves, when the instru- 
ment' was rotate 1 upon its diameter, was perfectly healthy as far as the neck of the uterus; 
but here th ; cause of the disease became evident. Towards the smallest part of the ex- 
tremity of the neck of the uterus, on the right side, an ulceration was discovered exhibiting 
all the exterior characters of a primary syphilitic ulcer. Its diameter was about three lines, 
its edges were regularly round, cut as with a punch, and its bottom presented a grayish 
tint. Around the ulceration was an areola of a bright red color, about four lines in width. 
All other parts of the neck were in a healthy state. 

There were seen, though with difficulty, traces of the purulent secretion furnished by the 
chancre, which was constantly bathed l>y the uterine and vaginal mucosities. 

Finally, the orifice of the neck was healthy, and secreted transparent mucus, without 
anv admixture of pus. 

We may here remark, that during the investigation, the patient experienced no pain, and 

103 



104 EXPLANATION OF PLATE VI. 

it was, also, the absence of" all morel id sensibility during sexual intercourse, which had 
satisfied her that she was free from disease. Moreover, direct pressure applied to the ulcer 
of the neck, revealed no disagreeable sensation. Matter taken from this chancre was in- 
oculated in the thigh, and the characteristic pustule and sore were developed. Finally, the 
disease was cured by the general chancre treatment. 



EXPLANATION OF PLATE VI. 

This plate is intended to present the genital organs of the female, conveniently disposed 
for the examination of the neck of the uterus with the assistance of the speculum. The 
design is taken at the moment when the surgeon has confided the handles of the instrument 
to the patient, the hand of whom rests on the genito-crural fold. We can thus dispense 
with the aid of an assistant, whose presence is always disagreeable in such cases ; and the 
attention of the patient, fixed by the care she takes to discharge the functions which have 
been committed to her, is not without advantage in preventing her from making inoppor- 
tune movements. 

The woman is lying on an operating chair, the pelvis raised, and the thighs and legs bent- 
When the patient is in this position the speculum should be introduced nearly horizontaly, 
with the handles directed to the side, as seen in the drawing, taking care to avoid pressure 
against the pubic-arch. 

On the two sides are seen the folds of the mucous membrane of the vagina; at the bot- 
tom, the neck of the uterus projecting between the valves of the instrument. On the right 
side of the extremity of the neck of the uterus, is a chancre surrounded with a red areola. 
Everywhere else the membrane is of a natural color. The sides of the ulcer, the bottom 
of which is grayish, are round and deeply cut in. 

From the mouth of the uterus, is escaping transparent mucus, which flows on the poste- 
rior lip of the neck, and is seen collected on the valve of the speculum placed below. 

On the right thigh is a chancre produced by artificial inoculation as seen five days after- 
wards. 



rum \u\ >\ iMiii.is— CHANCRE. L05 

antiphlogistic treatment and regimen, and general and local bleeding may be 
indicated. On the oilier hand, a purer air, better clothing, a higher diet, and even 
tonus may be required, where the constitutional tendency is the reverse. In cases 
of severe inflammation, if must be reduced, before the caustic can be used with safety, 

and in such cases, it is sometimes not proper to employ it at all. 

1 > 1 1 11 11 ur the reparative Btage of the chancre, and as long as any hardness continues, 
the use of mercurial dressings and frictions around the part affected, with a mild mer- 
curial course of constitutional treatment must he persevered in ; and in this is the 
best warrant of a perfect cure. I prefer to use frictions in all cases, and these alone 
may he sullicient, where mercury disagrees with the stomach and intestinal canal. 
Caustic may he used in the final stages, in keeping down the exuberant granulations ; 
it may also he passed lightly over the surface, to promote cicatrization. For these 
purposes the nitrate of silver is generally preferred, but there are cases in which the 
sulphate of copper may be used to greater advantage. 

It remains for us to consider some chancres of particular situations, characters 
and complications, which must modify the treatment. 

Chancre in the urethra causes a discharge as in gonorrhoea, with inflammation. 
Antiphlogistic treatment must be resorted to — leeches applied to the perineum and 
penis, emollient poultices and baths, opiates with camphor to prevent erections, 
and diluent drinks in large quantities : if abscesses appear at the mouth of the urethra 
they should he opened and the caustic applied. The chancres in any part of the ure- 
thra may be felt, if carefully sought for, and may be cauterized by the aid of an in- 
strument invented for that and similar purposes. An injection of the aromatic wine, 
and a decoction of poppy heads may be used, or the wine alone, according to the in- 
flammation. It is necessary, sometimes, to wear a small cylinder impregnated with the 
dressing, in the urethra, or a bougie, if deeper seated, when the chancre is healing. If 
the discharge is dependent upon the chancre, it will cease with the ;ansc which pro- 
duced it; but if it be a complication, it must be treated as in other cases. The preven- 
tive mercurial treatment does not vaiy from that which is necessary when the chancre 
occupies external situations. 

In females, when the chancre is deep in the vagina, or upon or within the uterus, 
the speculum vaginae must be used at every dressing : when it occurs upon the anus, 
or within the rectum, great cleanliness must be observed and the dressing repeated 
at every stool, the operation of which should be rendered as easy as possible ; muci- 



106 PRIMARY SYPHILIS. — CHANCRE. 

laginous clysters may be given for that purpose. If lint cannot be retained without 
pain, the dressing must be simple injection. Care in diagnosis must be had in these 
cases, as such ulcers are sometimes mistaken for other affections of the rectum, and 
operations performed will only aggravate the complaint. 

Superficial chancres, which sometimes spread over the glans penis, require merely a 
slight cauterization, and a thin dressing of lint between the surface and the prepuce. 

In the phagedenic or eating chancre, when the frenum is destroyed, or the surface 
undermined, or bridges made, these parts must be divided to give a better opportu- 
nity for cauterizing them. 

When the phagedenic, diptheritic, or pulpy chancre makes its appearance, we 
must first direct our attention to the constitutional causes which have produced it. 
The dwelling of the patient may be cold and damp ; removal to a warm and dry sit- 
uation may be all that is required to make the disease assume a favorable character. 
A removal from a warm to a cold climate produces sometimes a very bad effect, 
while a beneficial result comes from a contrary movement. Whatever may be the 
general causes, the low state of the system must be the object of our first attentions : 
a proper constitutional treatment, a generous diet, tonics, and other invigorating mea- 
sures, will probably produce the wished-for change. 

The idea that the rapid progress and frightful appearance of this kind of sloughing 
chancres depend upon any special virulence of the poison, must not be entertained ; 
nor will it do for us to attack it by a violent exhibition of mercurials. These are to 
be used cautiously in this stage of the disease, as they frequently aggravate the 
symptoms. 

After and during the constitutional treatment, deep and frequent cauterizations 
and the vegetable astringent lotions must be resorted to. 

The immediate pain of cauterization with the nitrate of silver, should not prevent 
its frequent use in this form of the disorder, for, as Ricord truly observes, caustic is 
" the most efficacious sedative and certain antiphlogistic which can be applied." 
But should these means fail in proving beneficial, as they sometimes do, we must re- 
sort to other and various means. In some cases the fatty ointments, such as opium 
cerate with calomel, melted wax, or digestive ointments, may have a good effect. In 
others the most powerful caustics — the butter of antimony, caustic potash, and even 
the actual cautery have been been used to advantage. Ricord uses the Vienna paste, 
blisters, and powdered cantharides. 



107 PB1W \i;y SI PH1LI8.— CHANCRE 

But occasionally, in spite of cauterizations, emollients, antiphlogistic! or narcotics, 
the chancre will progress or remain stationary. In inch a case, the application of 
a Mister or powdered cantharides to a surface nicer, or the filling op of a deep-seated 

one with the same article lor twenty-lour hours, followed by an astringent dressing, 

lias promoted a healthy change. Sometimes it will he necessary to repeat these ap- 
plications. In extensive and undermined ulcerations, it is often necessary to destroy 
the thin surface, which is best done by caustics. 

Mercury must be used or avoided, according to its effects. In some cases, it evi- 
dently aggravates the symptoms. In others it seems indispensable to a cure. 

The most dreaded form of the chancre is that which is accompanied witli a high 
degree of inflammation, and is attended with gangrene, and the destruction of the 
organs of generation. It is generally caused by intemperance, or irritation, and is 
accompanied with general and local inflammatory symptoms, which it is our first duty 
to reduce. 

In these cases, we find the entire penis swollen to distortion, and colored a bright or 
purplish red, with a copious discharge from the point of ulceration. When the pre- 
puce is attacked with this inflammation, after a few days a black spot appears, which 
enlarges until the whole glans may be seen through it, and in this is involved the 
entire destruction of the prepuce, as what remains must be removed with a knife. 

In such cases, I do not assert that general bleeding is always unnecessary, but I 
have never had occasion to use it, and have generally found the febrile symptoms 
yield to tartar-emetic. The black wash, introduced with a syringe under the pre- 
puce, is an excellent application. When the destructive process has threatened to 
destroy the glans and involve the whole penis, washing the diseased surfaces with a 
strong solution of the muriate of antimony, or with nitric acid, has checked the gan- 
grene. In some cases, with patients of a peculiar temperament or condition, the in- 
flammatory and gangrenous action goes on uncontrolled, and the penis sloughs away, 
close to the pubes, leaving a mere apology for the organ, scarcely and with difficulty 
serving for urinary purposes. 

There is one condition of the sloughing of this organ, for the arrest of which no 
means have been found even tolerably effectual. It is when the portions attacked 
have a softness resembling melted tallow just beginning to harden. Colles, who 
had an extensive army practice, says he had never seen the destruction of the 
penis stopped for a moment, when attacked in this manner. 



108 PRIMARY SYPHILIS.— CHANCRE. 

The hemorrhages which are often occasioned by the progress of the inflammatory 
gangrenous chancre, are sometimes favorable to the cure by relieving pain and in- 
flamation — but they are to be watched with care, for occasionally the grave symptoms 
are renewed and the bleedings recommence, until at length the patient sinks into a 
low, typhoid, irritative fever. Sleepless, haggard, emaciated, and in constant dread 
of fresh hemorrhages, he gets no relief, but by slitting the prepuce to the point of 
sloughing, and compressing the bleeding vessels with a dossil of lint dipped in spirits 
of turpentine, which acts as a stimulant as well as a styptic. Ligature is of little ser- 
vice in these cases. In the use of the turpentine spirits, the neighboring parts must 
of course be protected from its fiery irritation. 

Sloughing of the prepuce has been considered as so effectual a cure of the spe- 
cific nature of the disease as to prevent secondary symptoms. It would be unsafe 
to trust, to this although there were no facts to prove the contrary. 

There remains but one form of the primitive chancre which is of sufficient impor- 
tance lo call for special attention. It is that of which I have spoken as the indura- 
ted. Of this kind there are two principal varieties, the simple and the phagedenic. 

When induration takes place in a simple chancre, whether it be the result of cau- 
terization, or a characteristic symptom of the disease, the use of caustic must be at 
once abandoned. If it suppurate freely, it may be washed with aromatic wine and 
treated with an ointment of mercury and opium. Great care must be taken in the 
dressings, as irritations are apt to produce unmanageable sloughings. 

Nothing is more likely to prove useful in these cases than the exhibition of mer- 
cury, both internally and by friction, especially the latter ; and as long as induration 
remains, there is no safety against the breaking out of the chancre as well as the ap- 
pearance of secondary symptoms. 

In indurations, the French surgeons have used with success the mercurial prepa- 
rations which are combined with iodine, as the proto-iodide of mercury. Ricord 
recommends it, in one grain doses, in combination with henbane, every night in a 
pill five hours after the last meal; after a week the dose is increased, and a pill 
taken both night and morning. The pills are to be continued after cicatrization, 
and gradually diminished. Salivation, if possible, is to be avoided, as the irritation 
which attends it is unfavorable. 

Excision of the indurated chancre can seldom be practised. It must be com- 
plete, to be effectual. 



PK1MAKY SYPHILIS.— CHANCRE. 109 

When, from excessive induration, the chancre takes on a phagedenic character, 
it is to be treated for the canst; rather than efiect, and mercury, not generally used in 

•sloughing smvs may here be need with success. Irritation and aeryons excitement 
may be met by the opium solution locally, and morphia internally used ; and in all 
these complications, nothing is so important as quiet and rest. 

Before closing my remarks upon this class of primary syphilitic symptoms, I am 
anxious to impress the importance of a prompt abortive treatment in the first in- 
stance. If there is any doubt in regard to the syphilitic character of a sore, inocu- 
lation is an easy and a sure test, but of course it is to be practised upon the patient 
alone. In the complications and varieties of chancre, the general health cannot be 
too carefully attended to. When the system is in its proper tone, the disease is easy 
to manage. I trust that the importance of the mercurial course in all cases need not 
be farther insisted upon. 

The concealed chancres of the urethra demand the surgeon's utmost care. Very 
recently I have had a case of undoubted secondary syphilis, which I can trace only 
to a supposed gonorrhoea ; the result proves that the blenorrhagia was either produ- 
ced by or was complicated with a chancre. Here again a true test is to be found in 
inoculation. 



PLATE VII. 



PRIMARY ULCERS: EARLY SECONDARY SYMPTOMS. 



The subject of this drawing, 35 years of age, of good constitution, had never had syphi-"- 
litic disease before the present attack, and had always been perfectly free from eruptions on 
the skin. She presented herself for advice on the 8th day of July, with a chancre on the 
external labium, which had been first observed eight days previously, and a pustule seated on 
the internal labium, that was first noticed four days before our interview. 

The chancre was indurated, and its edges were abrupt and elevated. 

After having ruptured the pustule, the nitrate of silver was applied to both sores. They 
were then dressed with lint moistened with the yellow-wash. A pill of blue-mass, contain** 
ing five grains, was administered morning and evening. 

At the end of two weeks of treatment, both chancres had cicatrized, and the gums were 
quite sore from the influence of the mercury, which was, therefore, suspended for a few 
days, until this accident had disappeared, when it was resumed again in the dose of one 
pill at bed-time. In this manner the patient was kept under the action of mercury for three 
weeks, at which. time the case was considered to be cured. The decoction of sarsaparilla 
was directed for another week, when every vestige of the disease having disappeared, all 
further medication was discontinued. 

At the end of a month, on the 25th of August, the patient re-applied for advice for an 
eruption of roseola that was distributed in patches over the whole cutaneous surface, re- 
sembling the drawing in Plate XV. with some swelling and inflammation of the fauces and 
tonsils. 

The treatment consisted in minute doses of the bichloride of mercury in pills, and vapor 
baths every other day, for a week. In about ten days the eruption had vanished and the 
skin had resumed a natural appearance. 

The mercurial was laid aside, and the iodide of potassium administered, dissolved in a 
concentrated compound decoction of sarsaparilla. Two scruples of the salt were added to 
eight ounces of the decoction, and given in the dose of a table-spoonful three times a day. 
Warm baths were ordered once or twice a week. This plan of treatment was continued 
for a month, when the patient was dismissed, apparently perfectly free from all disease. 

Three years have since elapsed, and, not having heard anything to the contrary, I am 
satisfied the last treatment was effectual. 

110 



PLATE VIII. 



NON-INDURATED PRIMARY ULCERATION OF THE UPPER GUM. 



NON-INDURATED PRIMARY ULCERATION OF THE FRENUM, 
(PERFORATING CHANCRE) : PARAPHYMOSIS. 



INDURATED GANGRENOUS CHANCRE : VESICULO-PUSTULOUS 
ERUPTION: EARLY SECONDARY ACCIDENTS. 

FIRST CASE. 

Here is a virulent primary ulcer of the gum, contracted by the application of the mouth 
to the genital organs of a woman affected with chancre. 

This is the only example that we have met with ; and this proves that chancres of the 
gums are much more rare than virulent ulcerations of the lips and of the tongue, which we 
have had occasion to observe many times. This ulceration, which is not of long standing, 
followed the ordinary progress of non-indurated chancre. It was cured under the influ- 
ence of cauterizations often repeated with the nitrate of silver, and of lotions with the aro- 
matic wine. 

The design, in signalizing this example, is to prove that the inoculable virulent syphili- 
tic pus, has not for its seat of election such-or-such organs in particular, and that it acts al- 
ways, at first locally, in every place where it meets with the conditions necessary for its 
development. This case proves, farther, that the gravity of syphilis does not depend, as 
has been said, upon the situation of the primitive accident. The patient had not received 
any constitutional infection, as we were able to verify, a long time after such symptoms 
ought to have been manifested. 

112 



o 



■ 



* 



"5 




- I 








I 

■ 











EXPLANATION OF PLA I 'B \ III. I I '• 



SECOND CASE, 



Chancre is often mel with on the frenum, or in its vicinity. 

The introduction and confinement of virulent pus in the numerous follicles with which 
that region is furnished, the frets of the epidermis and the abrasion thai happen during 
sexual intercourse, constitute so many causes which determine the predilection of the pri- 
mary ulcer for this situation. 

We find, in the homogeneousness of the tissue of the frenum, the reason why the chancre 
that establishes itself on it is nearly always of tin- perforating kind. 

The part which, ordinarily, resists its invasion for the longest time, is that which encloses 
the artery. Sometimes it occurs that the virulent ulceration is cicatrized, before the frenum 
has been entirely eaten through ; but then the cure is longer in being effected ; and the fre- 
num, often reduced to a thread, may become the occasion of new accidents from its rupture. 
For this reason it is always most prudent to practise the section, as has been done on this 
patient, after the the following method: We cut, with a fine scissors, even with the two 
points of insertion. After the section, we must be careful to arrest the haemorrhage, the 
consequences of which, unimportant, in the first view, may become very grave. Persons 
have fallen victims to the effects of haemorrhages of this kind. Generally, we pinch with 
the fingers the parts whence the blood escapes, and cauterize them with the nitrate of sil- 
ver. The application of cold, agaric, and other haemostatic means, will frequently be suf- 
ficient. In some rare cases where the haemorrhage was obstinate, we have been forced to 
pierce the tissues with a pin, and make compression by applying a figure-of-eight ligature. 
Or we may at once, before dividing the frenum, place a ligature at each of the two extremi- 
ties, with a thread of silk. In this wa}' we certainly prevent haemorrhage ; and the ab- 
sence of pain during the section, compensates for that which is occasioned by the ligature. 

The treatment of this patient consisted in the cauterization of the ulcer with the nitrate of 
silver, and dressings were made with lint soaked in aromatic wine. 

Each inguinal region became, at the same time, the scat of an acute inflammation of a su- 
perficial ganglion. These buboes suppurated, and remained virulent in spite of the mercu- 
rial treatment that the patient had already undergone, before coming under our care. 



THIRD CASE. 



The patient, who furnished the subject of figure 4, (Plate VIII.) has a decidedly lym- 
phatic constitution. He was vaccinated in his infancy, and, up to the age of t\vent3 r -five, 
had never had a cutaneous affection. 

The day following an impure connexion with a public woman, he perceived an excoria- 
tion on the limb of the prepuce ; presuming that it would get well of itself, he adopted no 
treatment. The excoriation became an ulceration that indurated, and many ganglions in 
the groin swelled without occasioning much pain. 



114 EXPLANATION OF PLATE VIII. 

* For three weeks the ulceration remained indolent : it scarcely suppurated, and made but 
little progress. 

All at once it became inflammatory and painful, in consequence of excesses committed 
in drinking. The swelling increased; suppuration augmented, and the ulcerated surface, 
which had been grayish up to that time, was covered with black points, evidently gan- 
grenous. 

The prepuce had always been moveable on the glans, and habitually covered it; but the 
patient wishing to leave the ulceration uncovered, took it into his head one day to pull it 
strongly backwards, which resulted in a paraphymosis, complicated with a hard cedema. 

When the patient came under our care, the ulceration had continued for six weeks ; it was 
large and projecting; its base presented the characteristic induration, and there was an 
cedematous engorgement of the neighboring parts. Its sides were turned a little outward, 
but without being undermined. On its surface, rose-colored granulations, of the period of 
reparation, already appeared ; nevertheless, in some points, were still seen traces of the 
molecular gangrene which had existed. 

We found, in the inguinal region, many ganglions that presented to the touch a kind of 
elastic induration ; they were indoleut, isolated, and moveable under the skin. 

The absence of all treatment, the advance of the successive accidents, and the nature of 
the primitive ulceration, made us reasonably suppose, that in this patient, there existed the 
syphilitic diathesis. It is true, the ulceration had been gangrenous ; but the tardy gangrene 
did not. hinder the constitutional infection. 

We prescribed the decoction of sarsaparilla, a mild regimen, and baths. The ulceration 
was dressed with lint, spread with opiate cerate. 

The patient followed this treatment for about three weeks, when he experienced nocturnal 
pains over the eyes, and vague pains in the neighborhood of the joints ; he had besides, an 
engorgement of the posterior cervical ganglions, accompanied with distress in the move- 
ments of the neck. His color had become a little chlorotic. There was no trouble in the 
circulation, except a slight bruit-de-souffle of the heart. 

The skin, which up to this time had presented nothing particular, was covered with 
small red points, like flea-bites. This eruption was not over the whole body at one time'; 
it was seated on the trunk and members ; it had not been preceded, nor was it accompanied 
with fever ; it produced no itchings. 

Aside from the antecedents that we have noticed, no accessory cause of evolution could 
be appreciated. These red maculas, that a slight pressure caused momentarily to dis- 
appear, were soon succeeded by small miliary elevations, filled by a serosity, semi- 
transparent and grayish, that had raised the epidermis. As they advanced, they became 
like the vesicles of eczema. They were surrounded by a circle of rose-color, the tint of 
which grew deeper as the eruption itself progressed. They terminated by assuming the 
vesiculo-pustulous form of conoid varicella. 

The eruption continued for more than six weeks, but in every part it did not travel 
through all the different phases of its development. 

In many places it died away during the stage of maculae, without leaving any trace of 
its existence. 

A great many miliary or eczematous vesicles, that were dried up and absorbed, have left, 



EXPLANATION OF PLATE vili. 115 

auer their dessication, hut a slight desquamation of their epidermis, without .'my itaini 
remaiuing behind. 

\\ here the eruption had advanced farther the Liquid, which had become purulent was 
not absorbed; it formed, in drying, a great number of gray or greenish crusts, some of which 
adhered tor more than fifteen days. Winn they fell off, we found at the place they had 
occupied, a smooth reddish spot, surrounded with a gray border, produced hy the loss of 
the epidermis. 

The crusts that were prematurely removed, uncovered a slightly ulcerated surface; and 
we observed, after the dessication of some of the pustules, slight depressions and cicatrices 
of the skin. 

As to the primitive ulcer, its cicatrization was not obtained until after the disappearance 
oi' the cutaneous accident. It was dressed with lint, spread with the following ointment : 

fy. Unguent. Opii, part. xxx. 

Hydrarg. Proto-Chlorid. part. ij. M. 

No local treatment was adopted for the engorgement of the inguinal ganglions. That 
engorgement disappeared in about two months, and the induration of the chancre in about 
three months, under the influence of the general treatment below described. 

Every day, eight ounces of a decoction of the stalks of dulcamara, edulcorated with two 
ounces of the syrup of gentian. Every night, one of the following pills: 

R. T'roto-iodidc of Mercury 7 , 
Ext. Lactucarii, aa. grs. xlv. 
Ext. Opii, grs. xv. 
Ext. Conii, Siss. M. Divide in 60 pills. 

At the end of eight days, two pills were administered ; eight days afterwards, the dose 
was raised to three a day. At the same time he was directed to have two baths a week ; 
and his bowels were kept open with Seidlitz-water administered from time to time. 



EXPLANATION OF PLATE VIM. 

Figure 1. A non-indurated primary ulcer of the gum, at the period of progress. 

Figure 3. A non-indurated primitive ulcer of the frenum : paraphymosis. 

Figure 2. The same ulceration seen after the division of the frenum. 

Figure 4. Indurated primitive ulcer, with interstitial gangrene : period of reparation 
in some points. The patch above represents the vesiculo-pustulous eruption in different 
degrees of development. 



CHAPTER VI. 

PRIMARY SYPHILIS— BUBO. 

Bubo — its definition. — First symptoms. — Other causes than syphilis. — Men more liable than women to 
have them. — Chancres about the frenum most apt to cause them. — Diagnosis of syphilitic bubo. — 
Treatment — the abortive ! cold ; compression, and antiphlogistic regimen. — Treatment in a more ad- 
vanced stage. — When pus has formed, the bubo must be immediately opened.-— Treatment of the 
ulcer. — Inoculation a test of its specific character. — Mercuiy should be employed for its constitution- 
al effects. — Powerful stimulants or caustics iu some cases required. — Indurations following bubo. — 
Fistulous openings. 

Bubo is a circumscribed swelling of a lymphatic vessel or gland. It usually ap- 
pears in the groin, but may exist in the arm-pits, beneath the under-jaw, or in other 
situations. 

A venereal bubo is one which is the consequence of sexual intercourse, — a syphi- 
litic one is either produced by the absorption of the syphilitic virus, or is connected 
with the secondary symptoms which I shall consider hereafter. 

Often the first indications of a bubo is the swelling of an inflamed lymphatic ves- 
sel extending from the chancre, along the penis, to the groin. At the first inflam- 
mation and swelling of the gland, it is moveable, but it soon becomes adherent to the 
surrounding tissues, and the skin itself is implicated in the formation of the tumor. 
When the swelling is great, the circulation of the limb may be impeded, causing a 
varicose state, or cBdema, or both conjoined. 

The first question in regard to a bubo is, what is its character 1 Out of a hundred 
buboes only about twenty are truly syphilitic. These are neither more nor less than 
deep seated chancres, whose development, suppuration, and termination, according 
to the laws which govern chancres, proceed regularly, and can but seldom be pre- 
vented. 

116 



IMMMAKY SYPHILIS.-— BUBO. 1 17 

A !>ul><) may be produced by exertion, wet feet, wounds and oilier injuries. It is 

the frequenl Accompaniment of gonorrhoea, and in this case is supposed to depend 

upon sympathy with the irritation of the local disease. It may, in case of chancre, 
he only sympathetic, or it may be produced by the absorption of the virus, and as- 
sume, frequently, after suppuration, the charach r of a chancre. 

Men are more liable to buboes than women ; and chancres situated on or ahout 
the frennm in males, or about the meatus urinarius in females, more frequently pro- 
duce them than when thoy are seated elsewhere. The artificial chancre, or that 
which is caused by inoculation on the thigh, has never been known to cause a bubo. 

There seems to be no reasonable doubt that a bubo may be the consequence of 
direct absorption — that is to say, that the syphilitic virus under certain circumstances, 
may be carried to the gland, and produce the chancre there. 

There are no certain indications that a bubo is syphilitic. If there be undoubted 
chancre, particularly around the frennm of the male or meatus urinarius of the fe- 
male ; if the bubo appear in the second or third week ; or during cicatrization, if it ap- 
pear in a superficial gland, and especially if it tend rapidly to suppuration, in spiteof our 
efforts to prevent it, we may presume that it is syphilitic. Upon these circumstances 
must our prognosis be founded. At any time after its first stage, the syphilitic bubo 
may be expected to go on to suppuration. 

A bubo is liable to become indolent, or indurated ; and in either case it may be 
of difficult cure and protracted duration. While, therefore, buboes are non-syphi- 
litic in a vast majority of cases, the truly virulent are always to be dreaded, and 
carefully guarded against. To this end, I know of no better means than the appli- 
cation of mercurial plasters to the penis and the thighs in the early stage of the 
chancre, or following its extirpation ; they should be closely watched for, and, if pos- 
sible, treated in suck a manner as to produce their immediate abortion. 

Since, then, the diagnosis of bubo is, at best, obscure ; since in so great a majority 
of cases they are sympathetic, and not idiopathic ; and since, even when caused by 
the absorption of the virus, they may be, or apparently are, checked in the first stage 
of formation, the treatment termed abortive, is to be practised in the commencement, 
in all cases ; not that it is always effectual, but because that a bubo ought, if possible, 
to be prevented from advancing to suppuration. 

Prompt measures should therefore be taken to repel and to scatter them, for sev- 
eral reasons. They are often excessively painful, and always annoying. If indo- 



118 



PRIMARY SYPHILIS.— BUBO. 



lent, they may continue for a great length of time, and if indurated, they are still 
worse. They are liable to extend beneath the integuments and form frightful 
sinuses down the thighs and into the surrounding parts. When they suppurate, 
they sometimes leave large scars, which are the permanent marks of their ravages 
— indications which every man would wish to avoid. 

The cure of the chancre, I would here remark, cheeks the formation of a bubo. 
This is an additional reason why the caustic should be applied freely and promptly. 

At the first stage of the bubo, it may be treated Tike any other inflammation, and 
without reference to its probable cause. Ice, or cold water, and compression, have 
been found useful in dissipating the swelling which has commenced. Some sur- 
geons very strongly recommend compression, which proper bandages will very easily 
supply. [See the cut.] A reclined position, coolness of temperature, and what may 
be termed a general antiphlogistic regimen, will be favorable to whatever measures 
may be used for abortion. 




Truss for Compressing Buboes. 

If the bubo is somewhat advanced when the surgeon is called, it is still his duty, 
if possible, to effect resolution ; and whatever his doubt in regard to its nature, he 
has this reflection for his comfort, that if the bubo be sympathetic, it will probably 
yield to his prescriptions — if syphilitic, they will do no harm ; though in this case, 
after a certain period, suppuration is inevitable. When there is pain, redness, heat, 



l'KIM All V SYPHILIS.— i:i:|;o 119 

ami swelling, vigorous antiphlogistic treatment must be resorted to: general bleeoV 
in':, leeches, nauseating doses of tartarized antimony, cold washes, ice. Should 
these not be successful, warm fomentations frequently changed, or cloths dipped in 

warm water, m.iy prove more eH'cctivo. In an extensive practice lor Several years, 
I have frequently known a thick plaster of mercurial ointment to he used with 
excellent effect. Such a plaster, with the compress, and mercurial frictions on the 
inside of the thighs, is perhaps the best treatment for the indolent type a bubo often 
takes on after passing its inflammatory stage, and losing its tendency to suppuration. 
To produce this resolution of the tumor a more vigorous treatment is often necessary. 
A blister may be placed upon the bubo, followed by dressings of the mercurial oint- 
ment, and succeeded, if necessary, by other blisters. 

A still more energetic treatment has been recommended by Malapert, a French 
army surgeon, and approved by Ricord. It is the following : Apply a blister, the 
size of a dollar-piece, for twenty- four hours. Then raise the cuticle and cover it 
with a piece of lint of a corresponding size, well saturated in a solution of one scruple 
of bichloride of mercury to one ounce of alcohol. Keep it in place from two to four 
hours — then cold applications for some hours ; when, Monsieur Malapert assures us, 
an eschar will be formed, and the tumor will subside. But Monsieur Malapert does 
not inform us of what we have already surmised, that this is a very painful treat- 
ment, and that a scar follows the cure. 

Acton recommends that after the blister, a solution of the corrosive-sublimate in 
water, twenty grains to the ounce, be applied to an indolent bubo for one or two 
hours, if the patient can bear it, followed by an emollient poultice with laudanum. 

These plans may be used with good effect on the failure of milder methods, and 
will hasten either resolution or suppuration, when the latter is inevitable. In the 
latter case, we shall have an ulcer, the treatment of which does not differ, generally, 
from that of the chancre. 

But all these methods are useless, and worse than useless, by the delay they oc- 
casion. When the tumor shows fluctuation, and other indications of the existence 
of an abscess, especially if there is reason to suppose that the bubo is virulent, no 
a moment should be lost after the appearance of pus, before it is opened to allow 
its escape. The abscess will otherwise extend itself, and all the pus absorbed is so 
much virus carried into the system. 

When an opening is to be made, we should prefer the lancet to caustics, and be 



120 PRIMARY SYPHILIS. — BUBO. 

sure that it is sufficiently extensive, and made in the proper direction, which ought to 
be lengthwise of the tumor. If the tumor present a less formidable appearance, the 
opening may be less extensive, and in very mild cases, and especially in those which 
are not virulent, a simple puncture may answer every purpose. It is quite unne- 
cessary to press out the pus when the incision is made ; and in case the bubo is syphi- 
litic, no tent will be required to keep it open, as the virus will immediately ulcerate 
the cut surfaces. 

It is proper to add, that when the integuments of a bubo are blue, thin, and of a 
gangrenous appearance, distinguished authorities recommend that the opening be 
made, and the covering extensively destroyed at the same time, with caustic potash. 
I see no particular benefit in this method, and the choice between the caustic and 
scalpel may be left to the taste of the patient. 

The bubo, having become an open ulcer, by artificial or natural means, requires 
a careful treatment, and may assume many morbid conditions, which will prevent 
cicatrization. Here a correct diagnosis is of the utmost importance, as it must guide 
the treatment. Should the opening prove a simple non-virulent ulcer, as are a large 
number, we have simply to lower the inflammation with anodyne lotions, fomenta- 
tions, leeches, a low diet, repose, and gentle aperients, &c. Or, if the sore have an 
indolent type, more stimulating applications may be resorted to. Gentle pressure, 
by compresses and rollers may also be employed. Should there be sinuses, injec- 
tions are sometimes of great service, and with their use we may often dispense with 
additional openings by means of the lancet or caustic. The treatment of the non- 
syphilitic ulceration of the glands, however, is but accidentally connected with the 
disease which we are considering, and the common books of surgery may be prop- 
erly consulted in regard to such cases. 

But when the surface of the ulcerated bubo is covered with a thick, yellowish 
slough ; when the ulcer is indolent or disposed to spread; when its edges are red, 
angry, or elevated; when, in short, it developes a virulent and chancrous character, 
it requires the same treatment, as a chancre in any other situation ; and it must be 
remembered, that it may be truly syphilitic, although no chancre has been discov- 
ered on any other part, and though none has existed. In the latter case, it is the 
" buhon d'emblee," of the French surgeons. It is here that inoculation becomes a 
test as valuable as it is infallible, when properly made. All matter of the bubo will 
produce the characteristic pustule on the second day, when it has failed on the first. 



PLATE IX. 

DIPTHERITIC PRIMARY ULCER WITH A NON-INDURATED BASE : BALANO- 
POSTHITIS WITH EROSION : SYPHILITIC ROSEOLA. 

This patient was unable to indicate very exactly the epoch of the beginning of this 
malady. All that he could say, was. that for six months he lived with the same 
woman, when, after a sexual excess, he discovered quite lively pains at the extremity of the 
penis. The exploration of the parts could only be effected with much difficulty, because of 
the narrowness of the prepuce. Nevertheless, the patient ascertained the presence of a 
grayish ulceration in the middle and superior region of the corona glandis. 

Ten days after perceiving his malady, he presented himself for treatment. We found 
him affected with a balano-posthitis, accompanied with erosion ; the ulceration of the crown 
of the glans was a dipiheritic chancre, having an indurated base. The eight or ten days 
before presenting himself, he was treated with a concentrated decoction of poppy-heads, a 
pill of the iodide of mercury every day, with a ptisan of dulcamara. 

The 23d of June a drawing was taken of the parts. Nearly the whole of the glans was 
denuded of its epithelium, and presented a violet-red surface like that produced by a 
vesicatory, and which secreted a greenish purulent matter ; the mucous membrane of the 
prepuce showed a state in all respects the same. On the crown of the glans and the 
median superior region, was an ulceration covered with a false membrane, thick, 
pultaceous, and every where adherent. The base of this ulceration was indurated, and 
this special hardness was very well distinguished from the inflammatory tension of which 
the adjacent tissues were the seat, by a sort of elasticity which is proper to it, and which 
considerably resembles certain cartilages. 

The ulceration was dressed with calomel ointment ; and lotions, made of two parts of 
nitrate of silver and two hundred of distilled water, were applied to the excoriated parts. 
The contact of the glans and prepuce was prevented, by interposing a bandelet of 
dry linen. Diet, half an allowance. 

July 1st. The inflammatory swelling has nearly disappeared, and the balano-posthitis is 
notably modified. Suppuration is much diminished, apparently furnished only by the 
diptheritic ulceration, and by some erosions which persist in the groove of the gland. 

121 



122 EXPLANATION OF PLATE IX. 

A pill of the proto-iodide of mercury was given daily, with the sudorific ptisan and syrup. 
Dressing and regimen the same. 

July 10th. The ulceration of the crown of the gland is freed from the false pultaceous 
membrane that covered it. The mucous membrane of the prepuce presents no longer any 
erosions, and that of the gland shows only two or three very small excoriations. For the 
last two or three days, a partial stomatitis has manifested itself. The same general treat- 
ment : the ointment of calomel was continued, and the chancre touched with the nitrate of 
silver. Stop the lotions. The same regimen. 

July 15th. The stomatitis has made progress. The free sides of the gums are red, 
tumified, and bleed with facility ; the mucous membrane of. the cheeks, red and tender, is 
elevated by an oedematous swelling ; in the points corresponding to the sides of the teeth, 
it preseuts a longitudinal line, irregular and grayish, having the aspect of apthae ; the uvula 
is rough and tumified, and the throat painful. The ptyalism is quite considerable. 

The mercurial medication was suspended, the gums touched with a brush dipped in pure 
hydrochloric acid, and a gargle given made with the same acid. 

The patient took a bottle of Seidlitz-water. 

The chancre was touched with the nitrate of silver, and dressed with aromatic wine. 

July 21st. There was no more ptyalism, nor pain in the throat. The gargles of hydro- 
chloric acid were continued. 

The chancre, which for the last two days was dressed only with dry lint, is completely 
cicatrized, but its base still presents some induration. Directed half an allowance of food. 

July 27th. Left to day. On the prepuce and on the glans, the epithelium has resumed 
the normal appearance, and the balano-posthitis is definitively cured ; however, to conso- 
lidate his cure, we directed the patient to take, two months longer, the pills of the proto- 
iodide of mercury, with the sudorific syrup and ptisan. 

August 20th. The same patient has returned, not having submitted to the treatment 
which had been prescribed; and, considering himself decidedly well, he surrendered 
himself to numerous excesses in living. Therefore, from his own account, scarcely a dozen 
days had passed after he took his leave as cured, when he excoriated the cicatrice of the 
chancre. He contented himself with lotions of the water of mallows ; and soon, on 
the prepuce and on the glans, reddish spots were succeeded by small erosions that 
suppurated. The affected parts were slightly painful, but the disease followed a pro- 
gressive march. 

To day, the 21st of August, the seat of the primitive ulcer exhibits an eroded surface, 
covered with small granulations. On the gland and on the prepuce, some of the excoria- 
tions remarked by the patient, and of which we have already spoken, presented an 
analogous aspect ; finally, here and there, on the mucous membrane, are perceived very 
small reddish maculae. 

In the posterior cervical region we can feel many tumified ganglions. These ganglions, 
of the bigness of a little nut, and moveable under the skin, offer a sort of renitency or 
elastic tension, and are perfectly indolent. The hair, dry and dull looking, is detached 
with facility. 

There does not exist any other symptom of the constitutional infection. A drawing of 
the parts is taken. Allowed half a portion of aliment. 



i:\im. w \tion <>r PLATE EC. I J'-i 

A 1 1 m i -- 1 99d< Though the erosion-; of the gland and of the prepuce preseni all the exterioi 
characters thai belong to secondary affections, yet, as the patient had had sexual connexioni 
some days after he lefl ;is cured] we collect some of the \n\< on the Burface corresponding 
with itif seal of the primitive nicer, and we inoculate with 11 on the lefl thigh, with the view 
of ascertaining if there has been a new infection. The granulations thai show themselves 
on the gland and on the mucous membrane of the prepuce, are repressed with the nitrate 

of silver. The ;i roinatic wine is used as a dressing. We give B ])ill of the lactate of 
mercury and a diluent ptisan. Half an allowance of food. 

August 96th. The inoculation has produced nothing. 

By the action of the nitrate of silver, the granulations have been repressed, and the 
cauterized parts no longer project. The dressings with the aromatic wine arc continued. 
(Jive two pills. The regimen is the same. 

August 37th. The patient feels some slight disturbance of the stomach. The pills are, 
nevertheless, continued, in the quantity of three a day. 

The ulcerations are cicatrized. The dressings are discontinued. The regimen remains 
the same. 

In proportion as the ulcerations cicatrized, the small reddish spots, the presence of which 
we have noticed as being on the mucous membrane of the gland and on the prepuce, are 
extended, and, in many points, have assumed regularly circular configurations. 

The skin of the trunk and of the members, especially in the seat of flexion, show, to-day, 
in a verv apparent manner, an exanthematous confluent eruption, (syphilitic roseola) charac- 
terized, in the greater number, by full maculae, and in some points, disposed in a circle. 
This eruption, consisting, evidently, in a capillary fluxion, that is readily effaced under the 
influence of slight pressure and soon re-appears, offers a general tint of a sombre rose-color. 

In the intervals of the macula?, the skin, in appearance, is earthy. 

The same treatment and regimen. 

August 30th. The patient has had some colic and a little diarrhoea. Prescribed rice 
water, and an ounce of the syrup of diacode. Same treatment and restricted diet. 

The second of September a drawing was made of the eruption. There is no longer any 
diarrhcea. The treatment the same. Gave one quarter of the alimentary allowance. 

September 5th. The syphilitic eruption, which, for several days past, seemed stationary, 
shows a tendency to resolution, and it is generally turned pale. Gave him four pills, and 
half an allowance of food. 

September 6th, five pills: September 7th, six pills: September 8th, seven pills. 

September 9th. The tumifaction of the cervical ganglions no longer exists. The syphi- 
litic eruption has grown paler and paler, and the maculae are scarcely visible on the trunk. 
The treatment and regimen the same. 

September 11th. The cure progresses; the eruption on the penis is effaced. Gave eight 
pills of the lactate of mercury, and three quarters of the alimentary allowance. 

- ptember 20th. The cure of the syphilis seemed to be complete. The cicatrice of the 
primary ulcer presents no more specific induration. Treatment and regimen the same as 
before. 

October, dismissed cured. 



124 EXPLANATION OF PLATE IX. 



EXPLANATION OF PLATE IX. 

Figure 1. Indurated diptheritic ulcer, and balano-posthitis, with erosion, the drawing 
taken the 23d of June, the day after the patient presented himself. 

The oedematous prepuce is drawn backwards so that we may see the middle and supe- 
rior region of the base of the glans, with an ulcer covered with a false pullaceous mem- 
brane, adherent, and all the superior portion of the balanitic surface eroded. These parts 
have been cleansed from the pus that defiled them. 

Figure 2. Secondary ulcerations with granulations shooting' out, and commencing maculae, 
drawn the 21st of August. The parts are disposed in the same way as in the first figure. 

The seat of the primary ulcer is covered with numerous granulations, and there will be ob- 
served on the correspondent region of the prepuce, two small longitudinal erosions. At the 
base of the gland, and near the meatus urinarius, are groups of granulations as large as 
those of which we have already spoken, and which, produced by secondary excoriations, 
have a tendency to pass to the state of true vegetations. Here and there on the mucous 
membrane are very small reddish maculae. 

Figure 3. Drawing made the 2d of September, and disposed in such a manner as to 
show the eruption which has extended itself on the mucous membrane of the gland and on 
that of the prepuce. We see, at the same time, on the belly and on the thighs, the syphi- 
litic roseola, confluent, constituted by rose maculae, brownish, while those of the mucous 
membrane of the glans and prepuce are colored a lively red. The ring-like configuration is 
also much more remarkable in these last, and we can discover here the elements of their 
formation. Some of them, regularly shaped into a circle, surround small patches of healthy 
membrane ; while others, at first full, are healing from the centre to the circumference, the 
annular form showing itself more and more. 



PRIMARY SYPHILIS.— BUBO. 1.25 

Ricord round, too, thai the syphilitic matter was contained in an encysted tumor, 
which was (| iveloped soparate from the rest of the abscess. 

N\ hen inflammation, phagedena, or gangrene occur, they mnsl be treated on gene- 
ral principles, without regard to the specific nature of the bubo; and when these 
Bymptoms have yielded to the proper treatment, we turn again to the treatment of 
the specific chancre. 

Frequent and careful dressings — the more frequent the better, to keep the virus 
as much as possible from t ho secreting surfaces ; careful and thorough cauteriza- 
tions ; baths, and lotions of the aromatic wine, or other mild astringents, will gene- 
rally eradicate the virulent action : the reparative process will then commence, 
healthy granulations fill the whole cavity of the ulcer, and cicatrization complete the 
cure. I scarcely need say, that the mercurial, preventive course, should never be 
neglected in these cases, nor too quickly brought to a close, even though it may be 
a choice between two evils ; for any one who has seen as much of the effects of 
syphilis as I have, would rather be saturated with mercury than risk the slightest 
taint of constitutional venereal. 

The cure of the bubo may be delayed by its taking on an indolent character, and 
by the thin, livid edges of the skin, which the disease has undermined. To remove 
these, where such removal is expedient, the caustic is perhaps to be preferred to 
knife or scissors. The Vienna-paste, composed of five parts of quick-lime, and six 
parts of caustic potash, mixed with sufficient spirit, will answer for this purpose. 
Skin, apparently dead, however, has been saved by gently painting it over with nitrate 
of silver. 

Cauterizations may be performed with the nitrate of silver in solution, or the mine- 
ral acids, and some think highly of the acid nitrale of mercury. Ricord sometimes 
treats indolent buboes with blisters over the surface, and by filling the ulcerated cavity 
with powdered cantharides. Solutions of the chlorides of lime and soda may be 
used ; and a painful but successful application has been made of dusting over the 
surface a small quantity of the bichloride of mercury, and allowing it to remain for 
several hours. 

Frictions of mercurial ointment and of iodine around the parts may be resorted to 
with advantage, as also creosote, in a proper state of dilution. 

When the granulations are too rapid, they must be kept down with the lunar caus- 
tic, and a regular cicatrization may be promoted by passing it lightly over the sur- 



/ 



126 



PRIMARY SYPHILIS.— BUBO. 



face. An unhealthy cicatrix may be destroyed by partial and repeated applications 
of the Vienna-paste. 

Induration following bubo, must be treated with mercury as in chancre. If, how- 
ever, the whole bubo takes on the form of a scirrhous induration, it may be necessary 
to remove it by a severe operation, either with the knife, or by removing it layer by 
layer with repeated applications of a powerful caustic. The use of the Vienna-paste 
in such cases, though tedious and painful, is preferable to excision. 

Should the pustulous openings or sinuses, which sometimes form, resist injections 
of nitrate of silver, sulphates of copper and zinc, and bichloride of mercury, with the 
proper compressions and dressings, it may be necessary to open them at their lower 
point with the lancet or caustic, or even to lay open their entire length. This, if 
possible, must be avoided ; and here, as elsewhere, the disposition to use the knife 
unnecessarily, must be guarded against. 

I shall next proceed to the most important questions connected with the secondary 
symptoms of syphilis — the effects of mercury and other medicinal agents, and the 
prophylactic or preventive treatment. 




Inguinal Bandage. 



This cut represents a bandage which is convenient for confining poultices, and even for making mod. 
erate compression over the inguinal region. 







- 




I 




•S 4 




: ' ■:■-, - ■- 




V 



PLATE X. 

POLYMORPHOUS TUBERCULOUS SYPHILIS: ACCIDENT OF 

TRANSITION. 

Tims patient, 'J3 years of age, of a lymphatico-nervous temperament, was born oi'hcaltliy 
parents. His mother had had twenty-one boys and one girl. Eleven boys died of cholera, 
lie had had the small-pox in bis childhood, but since that time he lias enjoyed good health. 

In 1832, he was aflcetcd with an urethral Menorrhagia and epididymitis, both of which 
yielded to the use. of antiphlogisties, and of ordinary anti-blenorrhagics, without mercurial 
treatment. 

Two months later he applied with a discharge, symptomatic of an indurated urethral 

chancre. The pus furnished by the urethra was inoculated, and the results of the inoculation 

were positive. This time he was not affected with epididymitis, but there was an indolent 

ion of the inguinal ganglions. He was placed under the treatment of the prolo-iodidc 

aercury, in the dose of one grain a day ; then two, afterwards three. At the end of forty 

- he left cured. 

In 1833, this patient was treated during three months, in an hospital, for a cerebral affec- 
tion. In the course of the same year he returned ibr treatment, with ccthymatous syphilis, 
and some crusts of the scalp, which yielded to a mercurial course. 

In 1834, it appeared that he had a relapse of the cutaneous eruption, and subse- 
quently a non-indurated chancre on the prepuce. He had been treated for these accidents. 

In lS-:!-3, he returned with a Menorrhagia complicated with epididymitis. 

In JS:J-, he was treated anew ibr ecthymatous syphilis. 

In 13:39, he was again two or three times under treatment, in hospital, and left without 
being cured of the relapses of the constitutional accidents, for which he had already sub- 
mitted to many medications. 

Finally, the Gth of December in the same year ho returned with the tuberculous syphilis 
that made the subject of Fig. 1. (Plate X.) 

Already the patient had experienced cephalic and nocturnal prcarticular rheumatic pains, 
whilst the eruption that we arc going to describe developed itself. It first appeared on 
the pelvis and thoracic members, thou the face and the scalp. 

Isolated in some points, grouped in others, irised or scrpigenous, this eruption presented 

the following phases : maculre of a dark red and copper color, with a thickening of the 

epidermis; miliary granulations; tumors more and more voluminous, and surrounded with 

I irk red circle — some with integrity of the epidermis, others covered with scales; and, 

127 



128 EXPLANATION OF PLATE X. 

finally, others, after ulceration and suppuration on the surface, are clothed with crusts 
stratified and greenish. Notwithstanding, here and there may be observed ecthymatous 
pustules at the summit of the tubercles. In the points where the suppuration was established, 
after the fall of the crusts, spontaneous or artificial, we discover an ulceration with a red- 
dish bottom, the sides abrupt and irregularly rounded : where the squamae existed, the 
tubercle, after their fall, has preserved its prominence. Different times of arrest, different 
modes of progression or of termination, have rendered polymorphous the general aspect of 
this eruption, which has neither been preceded nor accompanied with fever. There has 
never been any itching, except on the scalp. 

Treatment for the accidents of transition to which the patient was subjected. 

Bitter ptisan, with fifty grains of iodide of potassium, daily. Every night, a grain pill of 
the proto-iodide of mercury ; then two ; then three, and at last four. 

After having, in the first place, detached, with the aid of cataplasms, made of fecula of 
potatoes, the squamae and the crusts, we covered the diseased parts with the pbister of 
ammoniac and mercury. Under the influence of this medication, the ulcer promptly 
Cicatrized ; the tubercles wiihered, and underwent a sort of gelatinous ramollissement. 

The cicatrices that succeeded to the ulcerations were depressed and irregularly rayed. 
Where there had been no ulceration was a tissue that was hard, projecting and gofred. In 
general, these cicatrices resembled those of burns or of scrofulous ulcers ; some of them, the 
Color of the lees of wine, continued for a long time vascular. 

After remaining this time fifty-five days under treatment, he appeared to be completely 
cured. Notwithstanding, in 1843, he went into a hospital for osteocopic pains. 

The 16th of February, 1844, he returned to us in the following condition: For the last 
month he had experienced very intense nocturnal osteocopic pains, that deprived him of 
sleep. Perfectly localized, these pains were seated on different points of the anterior face 
of the right tibia, on the left cubitus at its upper part, and on the malar bone of the same 
side ; these pains were exasperated by pressure, and the heat of the bed. On the place 
that they occupied, hard tumors were soon manifested, adherent by their base, without heat 
Or change of color in the skin, which continued moveable over them. The tumors seemed 
to become less and less painful under pressure, in proportion as their volume augmented. 

These new accidents were treated with the ptisan of hops, and a solution of the iodide of 
potassium, in the dose of one drachm daily. The osse'ous tumors were covered with 
plasters of ammoniac and mercury. 

Three days of this treatment were sufficient to remove the pains and afford sleep to the 
patient. 

At the end of fifteen days the tumors were already nearly dissipated. The treatment 
was continued to the 3d of June. 

Finally, on the 17th of September, he returned with the following symptoms: The two 
malar bones and the frontal bone in the supra-orbital regions, were the seat of a very 
distinct swelling, with some pains that increased under pressure and were exasperated at 
night. 

Independent of these local pains, the patient experienced at night severe cephalalgia, 
with affected vision of the left eye. Objects seemed to be multiplied and in leaping motion. 
He was nearly deaf in the right ear. 



EXPLANATION OF PLATE \. LS9 

The treatment consisted is the use of the iodide of potassium and a ptisan of vegetable 
bitters. On ijie 27th of November, all the symptoms thai we have described bad completely 
disappeared. 



EXPLANATION OF PLATE X. 

Figure 1. This figure represents differed phases of the evolution of tubercles. On the 
middle of die cheek, we see macule ; on the upper lip and the external and lower palpebral 
region, many small isolated tubercles; on the leftside of the nose, confluent tubercles ; 
which, more agglomerated towards the posterior part of the ala, constitute a single very 
voluminous tubercle. 

There may be further observed on the cheek, two pustules of ecthyma, with B tuberculous 
base, and surrounded with a dark red areola. On the lower pustule already appears the 
crust. 

Figure 2. This figure, erroneously denominated on the plate as secondary, is a tertiary 
affection. The subject of the complaint was a young gjrl who bad led a very dissipated 
lite. About fifteen months previous to the time the drawing was made, she had had 
primary symptoms, and had been in various hospitals, but it was unknown whether she had 
ever taken mercury. The principal features of the disease are well seen. The absence of 
papilla 1 on the tongue, where ulcerations had previously existed, excavated ulcers covered 
with a pulpy secretion, and surrounded with a red areola, bespeak at once the tertiary 
symptoms ; this is made more evident by the occurrence of rupia, which was present on 
various parts of the body. 






CHAPTER VII. 

SECONDARY SYPHILIS.— GENERAL DESCRIPTION. 

Always danger of secondary symptoms after the primary disease, if mercury be not employed. — Mani- 
fest themselves at uncertain times. — Most frequent form of secondary affections. — Tertiary affections. 
Secondary disease cannot produce chancre. — Secondary and Tertiary affections contagious. — Some 
reasons for this opinion. — Prognosis of constitutional syphilis. 

It is the opinion of Ricord, that when primary affections are cured by the abor- 
tive treatment, within five days after infection, no constitutional symptoms will follow. 
Mr. Acton, the English pupil of Ricord, more guarded, places the term at three days. 
My observation forces me to differ from both ; and while I allow that the chances of 
constitutional infection are greatly lessened, by a prompt destruction of the chancre 
by excision, or caustic, or by both combined, I could not feel myself justified in dis- 
pensing with such prophylactic treatment as I have already indicated. 

My reasons for this opinion are founded in the causes which produce secondary 
syphilis, or the means by which the system may become contaminated by the syphi- 
litic virus, in that modified form in which it produces the ever-to-be-dreaded train 
of diseases, that demand the utmost skill and judgment of the surgeon, and which 
sometimes set all known medical means at defiance. 

The secondary syphilitic affections may appear in two weeks after infection by the 
virus in its primary form ; or they may be delayed for months, or even years, the 
virus apparently lying dormant in the system, and ready to break out under circum- 
stances, which cannot, with any degree of certainty, be indicated. The laws con- 
nected with the constitutional development of syphilitic diseases, are involved in great 
obscurity. There seem to be persons who are never susceptible of general infec- 
tion. There are others, who, in some particular state of their constitutions, are not. 

180 



iNDARTZ SYPHILIS.— GENTOtAL DESCRIPTION. 131 

The »l • top nenl of secondary affections is thought to be favored by changes of 
diet, from ;i mild to an oxciting, or from a tonic to a debilitating one, and by similar 
changes of climate. The alteration from foetal to extra-uterine life, pregnancy, and 
the pe '1 of the cessation of the menses, influence its development. Certain Btates 
of the digestive canal, cutaneous diseases, and irritations of the throat and mucous 
membrane, are supposed also to have this influence. 

The most frequent secondary affections are febrile symptoms accompanied by cu- 
taneous eruptions, or syphiloids; ulcerations of the throat, opthahnia, or syphilitic 
iritis ; affections ofthe testicles, excrescences of the anus, and falling off of the hair 
and nails. These symptoms usually take place in the order mentioned, but not al- 
i, as ih Nil .sore throat, with ulcers of that and the neighboring parts, is 

often the first sign of constitutional infection. 

The syphilitic virus, modified to a certain extent, in the secondary affections, ap- 
pears to become still further modified when another set of symptoms make their 
appearance, termed tertian/. They manifest themselves, usually, a long time after 
the secondary symptoms ; are probably non-contagious, and are supposed to be trans- 
mi- sible only by inheritance, producing constitutional affections, usually termed 
scrofulous. 

The most common of those which are now distinguished as tertiary symptoms, 
are deep seated tubercles of the skin and mucous membranes ; pains and tumors 
of the bones and periosteum ; deep-seated tubercles of the cellular tissue, and a 
great variety of affections connected with all the tissues and organs of the system ; 
obscure in their diagnoses, of difficult treatment, but which may unquestionably be 
traced to constitutional syphilis. Among these are tubercular affections ofthe brain, 
lungs, and heart, and the destruction of the organs of hearing, sight and smell. 

It is considei i established point, that primary syphilis — the proper chan- 

cre, can only be produced by the syphilitic virus of a primary chancre or bubo. The 
experiments of Ricord have apparently settled this matter to the general satisfaction, 
may consider it as established that the inoculation of secondary syphilis will 
not produce chancre, any more than that of uncomplicated gonorrhoea. 

e Ricord, Acton, and, so far as I am acquainted, all modern writers rest, and 
draw from such premises the conclusion that the subsequent venereal affections are 
not contagious. This idea it will be my duty to contradict, because I cannot allow 
myself the space to controvert it. I proceed, therefore, to lay down what my observa- 



132 SECONDARY SYPHILIS.— GENERAL DESCRIPTION. 

tion, and the results of my inquiries teach me to believe arc the laws by which the 
transmission of constitutional syphilis is governed. 

The constitutional affections, termed secondary and tertiary symptoms, arise — 

First. From the absorption of the primary syphilitic virus into the system, from a 
chancre, or bubo. 

Second. From a direct absorption of the virus, which produces its secondary effect 
without the appearance of primary symptoms. 

Third. From absorption of the virus in the secondary stage. 

Fourth. From direct transmission from one or both parents, at the period of con- 
ception. 

Fifth. By being transmitted, from the foetus to the mother, by the foetal circulation. 

Sixth. From absorption of the matter by the nurse, from a contaminated infant, 
or by the infant, from a diseased nurse. 

I am satisfied that in any of these ways may secondary syphilis arise; and that 
though, in many cases, such causes do not produce such effects, it appears certain 
that they often do, and always may. 

The law seems to be that primary symptoms are required to produce primary, 
but that the virus, both in its primary and secondary stage, may give rise to consti- 
tutional affections. At what period the poison loses its virulence so far as to pro- 
duce no effect from absorption, is a very difficult matter to decide ; but I should be 
very sorry to submit a healthy person to the contamination of the syphilitic virus in 
any of its stages. 

We know that the slightest taint, producing scrofulous and tubercular affections, 
may be transmitted to offspring to the third and fourth generation. 

Absorption is not enough considered as a cause of disease, nor is the absorbing 
power of the surface of the body sufficiently dwelt upon, in considering the causes or 
the cure of diseases. 1 have recommended the introduction of mercury by frictions, 
and fumigations. A very large quantity of this medicine may thus be taken into the 
system. There is no reason to suppose that the virus of syphilis is not as subtile, 
and as freely absorbed, as this ponderous though fluid metal. 

A very simple experiment will satisfy any one of the powers of absorption in the 
skin, in certain cases. Immerse a finger in spirits of turpentine for fifteen minutes, 
and from half an hour to an hour afterwards, it may be smelt in the urine. The 
whole crew of a ship, loaded with naval stores, has been affected, the second day out, 



SECONDARY syphilis— GENERAL DESCRIPTION 188 

with violent strangury ; and the crews of vessels having' mercury for part of their car- 
-. have experienced severe ptyalism. In fact there is scarcely any poison which 
iikiv not be administered so as to produce its specific effect, by absorption. 

The smallest quantity of the vims, is sufficient to cause a general infection, where 
circumstances favor its development. What conceivable quantity can be smaller, 

than t!;.it which poisons the germ of fatal life, by which a man communicates the 

» 

curse of existence in the very moment and bv the very act of giving existence itself 
to a new being ! yet this is sufficient to produce a diseased abortion, or the deve 
lopment of secondary symptoms soon after birth — sufficient even to taint the vital 
current, which tlows back from the rudiment of infant-life to the mother's heart, and 
involve her, also, in its terrible consequences. 

It is because of this liability to absorption, by two bodies in contact, that a yonng 
should never be allowed to sleep with an old one, as the former loses, while 
the latter gams by the conjunction. This matter was very well understood as long 
as the days of king David, who, as he grew old, and decrepid — as the fires of 
life were burning low — received a new accession of strength, from sleeping with a 
yonng, beautiful, and vigorous- maiden ; and Abishag was repaid for this drain upon 
her constitution, by the immortality which this connexion with the great monarch 
has conferred upon her. 

That secondary syphilis is tran smissible from father to child, as the result of direct 
impregnation ; from mother to child, by foetal circulation, if not by the previous ova- 
rian infection ; from the child to the mother through the circulation, and from the child 
to the nurse, or vice versa, will scarcely be disputed by any but those, who either en- 
tertain the wildesl and most absurd theories in regard to venereal diseases, or who 
ly that there is a specific disease at all. 

It is a comm >n case for a man who lias been affected with syphilis, and supposes 
himself cured, to many a b ■alJ.iy. and unquestionably virtuous wife. She -conceives, 
an I al th sixth or seventh month of utero-gestation, miscarries, and is delivered of 
i 1 child, which presents all the appearances of incipient mortification. A second, 
a third, or fourth time, the same result takes place, and it is fortunate if the medical 
attendant makes the proper inquiries, and traces these unhappy occurrences to their 
proper source. If he do so, and put both husband and wife on a proper coarse of 
•meat, predicated upon the probable existence of constitutional syphilis in one 
and possibly both parties, the next child will likely be born at the proper time, and 

thout any indications of disease. 






134 SECONDARY SYPHILIS. — GENERAL DESCRIPTION. 

Abortion, however, is not caused in all cases. Sometimes the child is born alive, 
and apparently well, but the symptoms develope themselves soon after. This is more 
apt to be the case, I think, when the child receives the infection at some time after 
the commencement of its foetal existence. 

What a shocking state of things is here disclosed ; yet scarcely a street in our city 
but might give its examples of the horrors of syphilis ! 

The effect of the syphilitic virus in the nurse upon the child she suckles, has 
been known as long as the syphilitic disease has been subject to medical investiga- 
tion. There is nothing more natural than that the milk of the nurse should carry 
the disease to the infant ; yet there is reason to suppose that it is either wholly, or 
in part the result of absorption from the contact of mucous surfaces and the erectile 
tissues, of which both the lips and tongue of the infant, and the nipples of the nurse 
are formed. There is no question that the nurse may be diseased by the infant, and 
direct absorption, in this case, can be the only means of communication. In such 
accidents, sores break out, both around the mouth of the child, and the nipples of 
the nurse. 

It is in regard to direct infection, by absorption, occurring between one adult per- 
son and another, that the greatest difficulty may arise in giving a correct diagnosis ; 
but even here, my opinion is supported by a mass of observations, the evidence of 
which seems to me to be incontrovertible. I have known gentlemen, performing the 
duties of nurses for their sick friends, who had absorbed enough of the virus to pro- 
duce well marked tertiary symptoms, from continued and frequent frictions with the 
hands, not mercurial of course, but used to alleviate pain from exostosis and osteosis. 
The facility with which poisonous matter may be absorbed, the frequent and long- 
continued contact of mucous and other surfaces must be relied upon, to account for 
the existence of secondary syphilis in cases where primary symptoms have never 
made their appearance, and where there is no reason to suspect the probability of 
any other means of infection. 

I have thought it my duty to dwell thus particularly upon this subject, as it is one 
of the greatest interest to society, and one which, if properly understood, might lead 
to a salutary reform in morals and legislation. 

The prognosis of constitutional syphilis is exceedingly difficult. If left to the nat- 
ural course of the disease, it will probably terminate in from two to six years ; and 
there are cases in which any treatment we may pursue does not seem to effect much 
variation from this result. 



SECONDARY SYPHILIS. GENERAL DESCRIPTION L85 

Sometimosthe ulcerations of the throal descend into the larynx, and the lungs 
and the patient dies of b BpecioB of consnmption ; or ulcerations, attacking the arte 
ries of the neck, destroy life by hemorrhage. Other cases terminate, after protracted 
tortures, in exfoliations of tin- large bones and the cranium. 

Some terminate with diseases of the stomach and intestinal canal, producing 
diarrhoea and vomiting. 

Some persons, to allay tin 1 pain of exostosis, take opium ; and the saturation of the 
system with this drug, while it seems to moderate the action of the disease, is liable 
to produce so much general constitutional disturbance, as to end, finally, in death. 

Others die of diseases of the lungs, liver, heart, or intestines. 

So universal is the spread of this virus in the system — so various are the means 
by which it terminates existence. 

During the progress of the disease, there is often observed a certain regular peri- 
odical increase of its force, followed by an apparent change for the better, which, in 
due time, generally about every three months, gives place to another relapse. The 
medicine taken just before this periodical suspension of the action of the disease, or 
this rally of the powers of the system, are supposed to work wonders. On the other 
hand, at the period of relapse, medicine and surgeon are both liable to suffer, be- 
cause in spite of both the patient grows worse. 

The treatment of such a disease as we have described, and which is liable to be 
communicated by so many means, which produces such deplorable results, to indi- 
viduals, to families, and to whole communities, cannot fail of being a matter of the 
highest importance. I shall proceed, in the next chapter, to a particular description 
of the nature and treatment of the secondary class of symptoms. 



PLATE XI. 



PUSTULO-CRUSTACEOUS SYPHILIS: SECONDARY SYMPTOMS. 



This patient, twenty-six years of age, born of healthy parents, vaccinated, of a deci- 
dedly lymphatic temperament, light hair, clear blue eyes, feminine face, contracted a chan- 
cre at the base of the glans, a year before he came under our observation. The chancre, 
at first but little painful, was indurated ; some lymphatic ganglions of the groin were en- 
gorged. The patient contented himself with dressings of mercurial ointment, and put the 
emplastrum ammoniac, cum hydrarg. on the groins. The plaster excited pain and the swell- 
ing increased. It was necessary then to apply leeches and emollient cataplasms, which 
subdued the inflammation without suppuration of the ganglions. Two months later, the 
patient experienced stiffness of the neck, many of the posterior cervical ganglions were en- 
gorged, and he thought himself affected with measles. The skin of the body and of the 
limbs was covered with red spots, unaccompanied with fever or itching. A doctor who 
was consulted, hesitated a little as to the nature of the eruption. After nearly a month, he 
was treated with the decoction of sarsaparilla and the syrup of Larrey. This treatment was 
continued for two months. The eruptions had then disappeared, and the patient thought 
himself cured. But three months had scarcely passed, when he was attacked with noc- 
turnal cephalic pains, with slight dysphagia and dysphonia, and the skin commenced anew 
to be covered^ with an eruption, though not on every part at once. 

Nearly four months had elapsed after the new eruption appeared, when we saw the 
patient for the first time. It was confluent on the body and the members, and existed in 
some points of the face. It consisted of small maculae of a vinous-red, some of which yet 
faded under pressure; of vesicles of different sizes, distended with purulent serum, and 
surrounded with a deep red areola, and others, more advanced, that formed already, veri- 
table pustules of different degrees of development. In proportion as the pustules became 
more voluminous, the pus concreted to form a crust, slightly convex, and set like a watch- 
glass in a circle of epidermis elevated by pus of new formation and still liquid, and sur- 
rounded by an inflammatory red areola, the epidermis of which, also, comes to be in the end, 
elevated by suppuration, when the circle formed immediately before, is dried. In this man- 
ner are produced, successively, new disks, and the crusts increase thus from the centre to 

136 



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i:\ri. \v\Tin\ OF PLATE \i. L87 

the circumference! Beneath these crusts are rounded superficial ulcerations, having b I 
marbled with gray and red. 

In the points where the eruption was very confluent, the ulcerations were transbordered, 
and lost, thus, the regularity of their form; in other points they had cut through the whole 
depth ol' the skin, and presented thickened, abrupt, and turned a little backward. 

l om the simple maculae, up n> the strongest development, we bad a series of forms, 
which, taken apart, constituted so many varieties of eruption, and merited different titles. 
In the parts intermediate to the eruption, the skin was pale and a little earthy. 

There existed a slighl bruit-de-souffle of the heart and carotids. At night there was a 
little fever. 

The patient was placed under the use of the decoction of dulcamara and syrup of gen- 
tian. He took at first, daily, eight pills of Vallet, and one grain of the proto-iodidc of mer- 
cury : then, after eight days, two grains of the proto-iodide of mercury and twelve pills of 
Vallet. The crusts were detached with the aid of cataplasms made of potato-starch ; the 
ulcerations were dressed with the following ointment : 

R. Hydrarg. Ammoniat. partes ij. 

Unguent. Sulphur, partes xxx. M. 

We directed for him two baths of bran-water each week, and a strengthening tonic. 
After about two months of this treatment, the eruption was cured, but, it was thought ad- 
visable to continue it for two months longer. 



EXPLANATION OF PLATE XI. 

On the back nnd arms is an eruption of different degrees of development: maculae, vesi- 
cuke, vesico-pustukc, and pustulo-crustaceas. 

We see most perfectly, on the arm, the manner in which the eruption progresses from the 
centre to the circumference. The crusts are surrounded by a circle of epidermis that the 
pus has raised. This circle is itself surrounded by a red areola, the epidermis of which is 
also elevated. 

Behind and below the arm-pit, is a group of superficial ulcerations, uncovered by the 
falling off of the crusts. 

At the bottom of the cheek, near the angle of the lower jaw, is a deep ulceration with 
projecting sides, and slightly turned back. 



CHAPTER VIII. 

SECONDARY SYPHILIS. — GENERAL PRINCIPLES OF TREATMENT-. 

Spontaneous cures. — Anti-mercurial treatment. — Effects of climate, clothing, diet, bleeding. — Ne- 
cessity of attending to the digestive organs. — Woody decoctions.- — Quinine. — Iron. — Iodine. — 
Mercury. — Preparations of gold and silver. — The experience of three centuries is in favor of mer- 
cury. The general rules for administering it : may be administered by friction, fumigation, and by 
the mouth. The different preparations : the iodide, the proto-chloride, and bichloride, the cyanuret 
and the deuto-phosphate of mercury, most usually employed; the calcined mercury. — The iodide 
of potassium. 

There may be, and probably are, persons who are not susceptible of the consti- 
tutional infection, or secondary symptoms of this disease. Or, it may be, that per- 
sons who are susceptible at some times, are not so at others. The particular state 
of the system, favorable or unfavorable to its development, is not known. Were that 
matter understood, and the means of producing the last named condition also known, 
the disease would be robbed of half its terrors. 

In a certain proportion of cases, very small indeed, the consecutive affections may 
also terminate, so far as we can judge, by a spontaneous cure ; whether because 
some constitutions have a peculiar power of throwing off the syphilitic virus, or 
whether they contain some properties which neutralize it, we cannot know. Acci- 
dental perspiration, changes of climate and mode of living, the conclusion of other 
diseases, have been considered the causes of such seemingly natural recoveries ; but 
there is not enough known in regard to those causes, nor enough certainty attending 
them, to render them at all to be relied on. 

I may state at once, that I have no kind of faith in what is termed the simple, or 
the anti-mercurial, or non-specific treatment of constitutional syphilis ; at the same 

138 



&E0ONPA&1 SYPHILIS cknkkai, PBIKCIPLEB OF TREATMEKT. L39 

time I would not underrate the importance of a proper general treatment in connec- 
tion with thai which is more specific. I shall, therefore, make some remarks upon 

wlial has hern termed the simple treatment. 

Climate has always an influence upon syphilitic patients. Symptoms, mild in 

Spain, have become greatly aggravated by the patient going from thence to Eng- 
land. A removal from a cold and wet situation to a warm and dry one, has often 
favored the treatment, and evidently tended to the cure of tin; most desperate cases. 
Quiet, a recumbent position, and a genial warmth, are particularly insisted on by 
those who rely upon a simple treatment; and, if favorable to a spontaneous cure, 
they may well be considered as proper whenever they can be attended to. 

Sufficient and good clothing, so as to maintain the warmth of the body, and the 
constant and healthy action of the skin, cannor/but be a matter of great importance 
in the treatment of a disease which we have so much reason to suppose tends to the 
surface, and may, in some cases, be thrown off entirely by the means of the perspi- 
ratory function. 

Diet is a matter of so much importance, that there have been those who have un- 
dertaken to treat syphilis by attention to this alone. The food, in kind and quantity, 
must be regulated according to the constitution and temperament of the patient. To 
prescribe a low diet in all cases, will be in many cases to produce inevitable mischief. 
An English physician, applied to by a poor patient, prescribed a great-coat, warm 
blankets, better food, and more of it. Persons of a full habit, inclined to inflamma- 
tory action, must be put upon a low, mild, but still sufficiently nourishing diet ; while 
in weak, debilitated individuals, with a scrofulous constitution, a spare diet aggravates 
the disease, while a generous tonic diet is an absolutely requisite part of a successful 
treatment. The diet must be adapted to the greater or less degree of inflammatory 
character of the disease, and also to the condition and habits of the patient. People 
who have been accustomed to low living, will generally be benefited by better ; while 
those who have been accustomed to high living, cannot be indiscriminately reduced 
even to the diet upon which the former may be put with advantage. With these 
general principles, the kind and quantity of food must be left to the judgment of the 
physician, whose business it is to see that all the functions of life are performed in 
a manner most conducive to health, and most favorable to the specific treatment of 
the disease. 

Whenever symptoms of super-excitation, and especially of inflammation, exist, 



140 SECONDARY SYPHILIS. — GENERAL PRINCIPLES OF TREATMENT. 

antiphlogistic measures ought to be resorted to, and that to the extent indicated by 
the nature and situation of the inflammation. In a somewhat extensive practice in 
this class of diseases, I have never been obliged to resort to general bleedings, yet 
I do by no means say that it is never necessary, and that it may not sometimes be 
absolutely required. But in all cases where they can be used, I prefer other anti- 
phlogistic measures, and I would particularly recommend the administration of the 
tartarized antimony in nauseating doses. The local application of leeches in certain 
cases of violent and circumscribed inflammation, is not to be neglected. 

Baths are much used in the treatment of every class of venereal diseases. The 
hip-bath is convenient for the local bathing of the parts more generally diseased. 
The baths ought to be tepid or warm, and neither of too high or low a tempera- 
ture. Baths medicated with gelatin, starch, bran, decoctions of poppy, henbane, 
and belladonna, are used in the medical hospitals of Paris. An attention to the 
perfect cleanliness, and the free and healthy action of the skin, can never be safely 
neglected, and the efficacy of baths to produce this condition need not be dwelt 
upon. The influence of baths as sedatives, without, or with the anodyne decoctions 
above noticed, is too well known to every physician to require to be more particu- 
larly enforced. 

The functions of the digestive canal, as well as the skin, should be performed 
with regularity. In the ulcerous forms of syphilis, and those in which the deep 
seated tissues are attacked, this is a matter of so much importance, that the condi- 
tion of the bowels seems to have a controlling influence over the progress of the 
disease. 

The use of sudorifics, especially some of the woody decoctions, has become to 
such an extent a part of the popular belief, that the surgeon may not be quite safe 
in rejecting them. Sarsaparilla is even supposed by many to possess specific 
powers in the cure of syphilis ; and this opinion has been encouraged by those who 
have made decoctions or syrups of this far-famed root, vehicles of mercurial prepa- 
rations. But though sarsaparilla is not the certain specific which many suppose, 
it has great power, and is not to be neglected. The ptisan of Feltz, is the one most 
approved in the French hospitals. Guaiacum appears to have more influence in 
diseases of the osseous system. 

Quinine, the bitter vegetable extracts, iron, particularly the proto-iodide of iron, 
and iodine locally or internally, in combination with mercury or otherwise, are to be 



ONDARY 3 YPHILI8.— GENERAL PRINCIPLES OF TREATMENT. Ill 

administered according as ionics or medicines for Bcrofula may be required. 

Preparations of gold and silver, have been highly recommended in preference to 
mercurj for the core of syphilis. M\ impression in regard to them is, thai they are 
never to be relied upon, and never used in preference to mercury, and are only to 
be brought into requisition when the latter, in all its forms and combinations, Tails. 

The experience of three centuries points to mercury as the great medicine for 
syphilitic diseases; the only one which deserves the name of a specific, and oven 
rhis is nol an absolute one. Mr. Hunter, assuming tho theory of irritations, supposed 
that mercury cured the syphilitic irritation, by causing another, and a greater one. 
It" a man really must have a theory, this may be as good as another. Other 
surgeons insisted that it was only by the drain of a profuse ptyalism that the virus 
was taken out of the system ; and mercury was poured into the system without 
stint, until that effect was produced. Now, we not only cure syphilis without the 
least symptom of salivation — but take all precautions against producing it, and 
cease the administration of mercury, and try to check the ptyalism as soon -as it 
appears. Others attribute the effects of mercury to its tendency to the surface, and 
its power of carrying other matters along with it ; and others believe that it chemi- 
cally or specifically neutralizes the syphilitic virus. 

My own opinions arc in favor of the last theory, and they are founded chiefly 
upon the fact, that mercury is so efficacious as a preventive medicine against 
secondary symptoms. I go no farther. Quackery consists in pretending to more 
knowledge and ability than we possess. I know that mercury produces certain 
effects — how. by what means, or in virtue of what laws, I confess 1 do not know ; 
and any view that I might advance upon such a subject would be of little value. 

It is impossible to lay down accurate rules for the administration of mercury, 
either in regard to its preparations or doses. In respect to the latter, only one gene- 
ral rule can be given. We must begin with small doses, and increase them gradually, 
up to the point where we perceive a favorable action, while at the first appearance 

soreness of the mouth which precedes ptyalism, or irritation of the stomach and 
intestines, (when these and other diseased actions arise from the mercury,) we must 
stop it for a time : commence again with diminished doses, change to other prepa- 
rations or modes of administration or combinations, especially with opium, which, 
next to mercury, may be considered the most valuable of our medicines in this 
disease — so valuable that many have supposed it to have specific virtues. 



142 SECONDARY SYPHILIS. — GENERAL PRINCIPLES OF TREATMENT. 

Among the indications that mercury is not agreeing with the system, in a particular 
form of administration, is an increased inflammation, sensibility, or irritation of the 
local symptoms. We cannot too carefully watch the appearance of such symptoms, 
nor regulate our treatment too closely by such appearances, because the continuance 
of mercury under such circumstances, is likely to lead to some destructive action, 
which may produce the most deplorable results. 

The state of the general system should also be closely watched, as well as the 
condition of the local affection. The less sensible the effect that is produced on the 
general system, either of febrile irritation or tendency to salivation, the better is the 
action of mercury on the disease; the better the patient "tolerates mercury," the 
more certain are its effects ; and, where mercury cannot be taken or borne, as it cannot 
by some patients, if the case is not desperate, we have, at all events, lost the sheet 
anchor of successful treatment. 

We must avail ourselves of all the information to be obtained of the patient in 
regard to the most efficient mode of treating his case. Thus we may inquire whether 
he has ever had the disease before, and of the method of administration and effect 
of mercury in syphilitic or other diseases. The information thus obtained may guide 
us safely, without the necessity of experimenting as cautiously as might otherwise be 
required. 

Mercury is administered by frictions, by fumigations, and by internal administra- 
tion. M. Ricord, for whose authority I entertain a high respect, prefers the inter- 
nal administration to all others, whenever the condition of the stomach and intestines 
will admit ; but I have said already, that, especially in the early stages of the disease, 
I never neglect mercurial frictions. It appears to me that the mercury in this form 
of administration enters the system more readily and certainly than by any other 
method, and that its effects can be more easily controlled. 

The mercurial ointment should be gently rubbed into the inside of the thighs, and, 
if necessary, of the arms, without occasioning too much irritation, and the parts 
should be covered by warm under garments, worn as long as the frictions are con- 
tinued, or, at least, during the night when the frictions are made. 

Fumigations are useful in obstinate affections of the skin, throat, and nasal fossae. 
The papular and pustular eruptions, and chronic ulcerations of the mouth and sur- 
rounding parts, seldom resist this powerful mode of administration. The necessary 
apparatus is very simple. The patient, confined to his room for five or six days, 



KCONDARY SYPHILIS. — GBNERAL PRINCIPLES OF THE \ i mi:\ r L4I 

which is kepi warmed to 7t) degrees Fahrenheit! and prepared by a course of low 
diet, aperients, and a compound decoction of ■arsaparilla, is seated on a stool, naked, 
in a chamber heated to SO" Fahrenheit. A robe of oiled, or waxed cloth, coming 

closely around the patient's neck, is to be placed over him, and under tins, upon the 
floor, a spirit lamp is placed, over which ;i china plate, containing einnebur, is to \n- 

arranged. The apparatus is now complete. The quantity of cinnebar necessary 

tor each fumigation is from twenty grains to a drachm. One application a day is 
sufficient, and they will generally produce their full effeel in from eighteen to twenty 
days. It' salivation, or other unfavorable symptoms ensue, we must of course modify 
or discontinue the process. When the treatment is terminated, the patient is to take 
a hath and change his linen. 

When necessary, the fumigation may be conveyed by means of a glass funnel of 
the requisite shape, into the bed of the patient. In any case it is usually employed 
in the evening, continued for about fifteen minutes, at the end of which time the pa- 
tient composes himself for the night. 

It is important that 1 should here mention some of the most approved forms or 
preparations of mercury, and their mode of administration, not so much because one 
preparation is better than another, as because where one will not produce the effect 
wished, another may; and in this point of view, a variety is desirable, if in no other. 
There is no doubt, however, that one or the other of the combinations of mercury 
with iodine, possesses peculiar virtues. 

•• The preparation," says Ricord, "to which I now give the preference, not only in 
the treatment of the secondary symptoms, but also of the primary, is the proto-iodide 
of mercury, commencing with a single grain, in the form of pills. In some patients 
tin; daily dose has been increased to six grains, and the total quantity has amounted 
to two hundred grains, by its being continued till the complete disappearance of the 
inptoins."' 

Tin proto-iodide of mercury is employed in primary syphlitic sores in strumous 
habits, hut is chiefly resorted to in chronic affections. This preparation is highly ap- 
proved by Cullerier, Biett, and others. M. Cullerier gives it in doses of from one- 
sixteenth of a grain to a grain, in the form of a pill, always in combination with opium. 
The pills of his formula contain half a grain of the proto-iodide of mercury, one-sixth 
of a grain of opium, and one grain of gum-guaiacum. In the form of ointment, this 
preparation may be used in frictions, both for general treatment and for a local ap- 



144 SECONDARY SYPHILIS. — GENERAL PRINCIPLES OF TREATMENT. 

plication to indolent ulcers and buboes. The patient during its exhibition, must be 
submitted to a strict antiphlogistic regimen. 

The proto-chloride of mercury, or chloride of mercury of the London Pharmaco- 
paeia, is extensively used in syphilis, especially in the chronic inflammations and ul- 
cerations of the testicle. In tubercles of the labia, and in various forms of creeping 
ulcers, and the ulcers of the mouth and nose, it is given in the form of pills, in com- 
bination with opium, or extract of conium. Ricord gives one scruple of the chloride 
of mercury, and two scruples each of conium in powder and castile soap, for twenty- 
four pills. The forms of other hospitals vary a little ; the pills at Val-de-Grace con- 
tain one grain each of the mercurial chloride and conium, and they are increased 
from one or two a day, up to twenty and even thirty, in twenty-four hours. One of 
the best combinations of this preparation of mercury, is what is commonly known 
as Plummer's pill, (the pilulse hydrag. chlorid. comp. of the London Pharmacopsea,) 
and in the secondary, and more especially the tertiary disease, there is scarcely any 
remedy superior to it. 

In. Germany and Prussia the bichloride is chiefly relied upon. It is given in pills 
containing one-fourth of a grain of the bichloride of mercury, to half a grain of opium. 
One a day for ten days, when, if necessary, the dose is increased to half a grain of 
the salt daily ; but others think that smaller doses are to be preferred, and give one- 
sixth of a grain in a dose, not exceeding three times a day. The usual German 
method is to give pills made of twelve grains of bichloride of mercury, and enough 
liquorice to divide into two hundred and thirty- eight pills. Half an hour after din- 
ner four of them are given ; the day but one after, six ; and so on increasing the dose 
two pills every other day, with one day's interval, till the patient takes thirty pills 
daily, containing a grain and a half of the salt. 

The cyanuret of mercury is by many, and for several reasons, preferred to the bi- 
chloride. It is more soluble, less liable to decomposition, acts more quickly, and is 
not so likely to cause pain and derangement of the bowels. It may be given inter- 
nally, either in pills or solution, and externally in the form of a pomade, or ointment, 
in which shape itis a very efficacious application to various forms of herpetic and squa- 
mous affections, allaying their violent Itching and irritation. It is also employed as 
a dressing for indolent ulcers and tubercles, and as a gargle in ulcerations of the 
throat. It may be given in combination with opium, in pills, beginning with a six*- 
teenth of a grain a day, and gradually increasing it. A solution may be made con^ 



SECONDARY SYPHILIS.— GENERAL PRINCIPLES OF TREATMENT 145 

taiuing from two to three grains to the pound of water, given in half-ounce doses. 
su eetened with sugar. 

In Italy the favorite preparation is the dento-phosphate of mercury, given in the 

same forms and doses as die bichloride. As an ointment applied to indolent bu- 
boes ami exostoses, it is by many preferred to all other preparations. 

Should the more common mercurial preparations fail, any of these may be re- 
sorted to, or via versa. In one case of secondary syphilis, which had defied the 
treatment of our best Burgeons, I sent to London for the calcined mercury, per se, 
and with that almost forgotten preparation, obsolete in the books, and not to be found 
at our druggists', I was fortunate enough to effect a cure. I can give no reason 
why this antiquated mercurial should have proved successful, when all other reme- 
dies had failed, except that it was different from them, and happened to be the form 
best suited to the condition of the patient and of the disease. 

Finally, the iodide of potassium, which of late years has been resorted to with the 
most singular advantage, is a remedy which I very commonly employ, in both the 
secondary and tertiary forms of syphilis. There is no one medicine, I am persuaded, 
from the most extensive experience with it, that can be compared to it in value. But, 
like all other powerful remedies, it has got to be a kind of panacea with many per- 
sons, and is indiscriminately administered, often to the manifest injury of the patient. 



PLATE XII. 



SYPHILITIC CRUSTACEA. (VARIETY OF CONVEX RUPIA.) 



This patient, a native of Ireland, 31 years of age, presented himself on the 23d of June. 
He was born of healthy parents, had a strong constitution, but had the lymphatic tempera- 
ment. 

Nine years since he contracted a Menorrhagia, and a chancre on the glans, which were 
soon accompanied with two buboes, that took the acute form, suppurated, and were not 
cured for more than a month after they had been opened with the aid of a bistoury. The 
chancre did not cicatrize for about four months. During the whole time that these accidents 
continued, he was treated energetically with mercurials, causing a strong salivation. No 
other symptom supervened, and his health was perfect during the four following years. At 
that epoch, the patient, who had always continued to see women, discovered a new engorge- 
ment in one of the inguinal regions, without any preceding disease. The progress of that 
engorgement was slow, it had little inflammation, little pain; notwithstanding, its size 
became very considerable, and terminated by suppuration. Seven weeks elapsed, after the 
spontaneous opening, before the cure took place. That time there was no specific treat- 
ment, and during three years afterwards, there was no other accident. 

Two years since, a few days after coition with a public woman, the patient perceived a 
small excoriation in the groove of the glans. The excoriation suppurated but little, and 
was accompanied with very slight itching. It soon took a rounded form ; its bottom was 
gray, and its base, which little by little attained an extent equal to that of the nail of the 
little finger, became projecting and excessively hard. But fifteen days, at the most, had run, 
since the beginning of this indolent ulceration, and already many ganglions of both inguinal 
regions were tumified, without much development, and without being painful. 

The patient was then subjected to a mercurial treatment, quite energetic, and which was 
continued for four months. He took, at the same time, bitter drinks, and confined himself 
to a severe regimen. The chancre slowly cicatrized, and the inguinal engorgements 
disappeared without suppuration. During the third month after, and notwithstanding the 
mercurial treatment, vague pains supervened in the vicinity of the great articulations, with 
a nocturnal pain over the orbit, which disappeared in about a month's time. The patient 
was thought to be cured, and the use of the mercurials was suspended ; nevertheless, 
eight months later, ulcerations were developed on the amygdalae, and the posterior cervical 

146 



I'l. Ml 




_-^. .».. 



i;\n. \\ \ PION OF PI \ rB III. I i; 

ganglions became tumified ; there wu pain in the movements of the neck. He recurred 
a to mercurials, and continued to employ them for nearly three months. 

1 lie cure seemed radical] but, al the end of Bis months, the patient saw forming on bis 
shins, small points of a dark red color, without pain and without itching. Small suppurating 
pimples succeeded to these spots, which gradually increased, becoming more and more 
purulent, and ending by drying and forming a crust. This crust, at first but small, slowly 
enlarged by its circumference. In those that were still increasing, an areola of vinous-red 
surrounded and preceded the new /.one of epidermis, raised up by the most recent suppu- 
ration, and which, in its turn drying, spread out more and more the base of the crust 
while this process was going forward, a pus escaped that was adhesive, reddish, san- 
gUinolent, and ichorous. In the points where the progress of the eruption was arrested, the 
crusts, which had been of a yellowish green, and then a greenish brown, became nearly 
Mack; they %\,re hard, horny, giving a dry sound on percussion, and no longer presented 
an areola. A slight circle of epidermic desquamation terminated their boundary. The 
eruption was limited to the inferior members: four on the right limb and one only on the 
left. On the right we could see the points of elementary departure, which consisted merely 
in a vesicular elevation of the epidermis with a dark red areola of great extent. This form 
of eruption, that commences nearly always by a small vesicle, and not by a bulla, may 
become arrested at that period which connects it often with ecthyma, before arriving at 
those proportions to which the epithet of rupia ought to be applied. 

Be it as it may, after the fall of the crusts, determined by the application of cataplasms, 
found, under that which occupied the internal side of the region under the knee, an 
irregularly ulcerated surface, and which, by its disposition, showed that it had been the base 
of a group of eruptions. A part of the surface was already cicatrized. In some points, the 
united ulcerations, irregularly surrounded with abrupt margins a little cvated, had a 
greenish-gray bottom covered with a pultaceous matter, analogous to that which is seen in 
primitive accidents in the period of progress. The crustaceous shell of the anterior part of 
the lciz, covered a surface of a vermilion-red, formed by granulations of a healthy nature, 
considerably elevated above the level of the surrounding parts. In other points the crusts 
covered only cicatrices of a brown color, and still vascular and arborescent. 

The eruption, that had lasted six months, was not the seat of any itching, and it was the 
sent of pain only during the period of advance, or when it was stationary. 

weeks before coming for advice, and a few days after a Inst sexual connexion, an 
ulceration was developed on the reflection of the semi-mucous membrane of the prepuce, 
and had soon invaded ;i part of the base of the gland. This ulceration assumed the 
progre.-s of pultaceous phagedena 

The treatment consisted in the use of a decoction of quassia, sweetened with the syrup 
of gentian. For the first eight days, the patient took a pill containing one grain of the 
proto-iodide of mercury and two-thirds of a grain of the iodide of potassium. Eight days 
later two pills, then three, and afterwards four, at equal intervals. The iodide of potassium 
was maintained at three grains during the whole time of treatment. 

After having detached the crusts, the ulcerations were all dressed with a solution of the 
tincture of iodine, (two parts of the tincture of iodine to one hundred of distilled water, with 

efficient quantity of iodide of potassium to make the solution.) 



148 EXPLANATION OF PLATE XII. 

After six weeks of treatment, the ulceration of the penis was cured, but it was about four 
months before the legs seemed to be perfectly cicatrized. 

Six months later, the cicatrices were yet a little bluish at their centre, and white at their 
circumference, rayed and figured in some points : they resembled the cicatrices of burns. 
The observation that we come now to make, is interesting in more than a single con- 
nexion, and constitutes one of those cases, which, alone, demonstrates the whole of our 
doctrine. The* patient had, in the first instance, a Menorrhagia, and a chancre with buboes. 
He perceived no induration in the seat of the chancre ;. the buboes suppurated ; no constitutional- 
accident supervened : it is true, a mercurial treatment was adopted, but we will see, later, 
if it is to that that we must attribute the absence of all consecutive symptoms. 

Lorig after that first disease, and following, in a few da}^, a suspicious sexual connexion, 
he discovered a bubo; — a bubo without any other antecedent, and that the favorers of the 
doctrine of bubons oVemblee regard as a new primitive accident. This ganglionic engorgement, 
the progress of which was, evidently, the same as that of sub-acute strumous affections, or 
of sympathetic or idiopathic buboes, suppurated. No specific treatment was adopted; no 
accident supervened. But, at length, a new ulceration of the genital organs followed a new 
coition ; it was excessively indurated, according to the expression of the patient ; the ganglionic 
engorgements accompanying it were small, remained indolent, and never suppurated. A new 
mercurial treatment was resorted to, which, like the first, was continued for four months, 
but did not prevent the successive evolution of constitutional symptoms, because it was 
insufficient. After a last connexion, a new ulceration manifested itself on the penis, when, 
the syphilitic diathesis being already established, it affected the phagedenic form, the patient 
having lost his aptitude to the indurated chancre. When the diagnosis has been rigorous, we 
can affirm that no constitutional accidents will supervene upon a non-indurated chancre with 
a suppurated bubo. The diathesis is not established, and, consequently, the mercurial treat- 
ment to which we render the honors of a cure, not only is useless, but it may be hurtful, 
altering the constitution and tending to render ulterior accidents more grave. 

We may rest assured that a bubo which is not derived from an indurated chancre, will 
not be followed with the phenomena of general infection. But we can assert that when a 
chancre presents the specific induration, and the engorgements of the neighboring ganglions 
remain indolent and do not suppurate, the diathesis is established, and the manifestations 
of constitutional accidents, with their successive forms, will happen within a given time. 
Finally, when, the diatheses is established, it appears to be no more apt to double or to treble 
itself than other diathesis; if the patient contracts new primitive accidents, they remain 
local; and, as a proof of this disposition, they never become indurated ; but, on the contrary, 
if the constitution has been long under the influence of the syphilitic diathesis, and has not 
undergone a methodic treatment; if a bad medication, and, above all, a mercurial medica- 
tion, has altered the constitution, the new primitive accidents have a great tendency to take 
a grave form, and often one of the varieties of phagedena. 



EXPLANATION OF PLATE xn. L49 



EXPLANATION OF PLATE XII. 

1. Crustaceoua eruption: Convex Rupia: crusts covering all the surface thai 
produced them. That on the anterior pari of the leg, resulting from a solitary eruption, ii 
quite regularly rounded ; the others constituted by groups of eruptions confounded together, 
have not so regular a Form. The crusts <>n the internal and posterior face of the calf, which 
is the furthest advanced towards a cure, is also the dryest, the blackest, and no Longer 
presents any traces of ail areola. 

On the anterior and internal part of the leg, is a vesicle, of the kind with which the rest 
of the eruption commenced. 

Figure 2. Ulcerations still in the period of progress in some points of the group constituting 
the eruption, and cicatrized in other points. 

gurt 3. Granulating ulcerations, at the period of reparation. 



CHAPTER IX. 

SECONDARY SYMPTOMS. — CUTANEOUS ERUPTIONS. 

The usual premonitory symptoms. — Exanthemata : the treatment. — Squama : their treatment. — Ve- 
siculce : their treatment. — Pustules — two species, the psydraceous, and the phlyzaceous : the treat- 
ment. — Papulce: treatment. — Tubercular, several varieties : treatment. — Ulcerations, Vegetations, 
or excrescences: treatment. — Condylomata, or Mucous Tubercles: treatment. 

The secondary symptoms of syphilis sometimes appear in fourteen days after in- 
fection, more commonly in five or six weeks, but may be delayed for an indefinite 
period, and finally may not be developed at all. 

They are usually preceded by languor, flying pains, disorder of the general sys- 
tem, and unrefreshing sleep. 

In persons in whom the sanguine temperament predominates, and febrile symp- 
toms are most apparent, cutaneous eruptions are generally the first symptoms of 
constitutional infection. 

The first form of these syphiloids, or secondary cutaneous diseases, is that of the 
exanthemata, which make their appearance in irregular patches of a shining red, 
bronze, or coppery color, according to the degree or the subsidence of inflammation. 
These patches, rarely confluent, and about an inch in diameter, are scattered over 
the whole surface of the body, but especially on the face, neck, forehead, mammse, 
or the genitals. These exanthemata are often complicated with other symptoms of 
constitutional syphilis, particularly iritis, and are succeeded by the squamous and tu- 
berculous eruptions. 

The general mercurial treatment of constitutional syphilis is never to be delayed 
a moment after the appearance of its first manifestations. No state of the general 
health or condition can be considered a contra-indication. Pregnancy, so far from 
being such, is an additional inducement. 

150 



SEi'o.NDAiiY SYMPTOMS.— CUTANEOUS ERUPTIONS. 151 

When there ia much fever, antiphlogistic treatment, and warm and gelatinous hatha 
in case of inflammation should be resorted to. [f the eruption prove chronic and 
obstinate, the cyannrel of mercury, or the bichloride with sndorifics may be employed. 

The favorite ptisan ofFeltz is much ased by Ricord for this state of the disease. 
It consists of a decoction of sarsaparilla, gum-acacia, and the snlphnret of antimony. 
The syrup of Larrey is preferred by others. 

Under this treatment, the eruptions may cither suddenly disappear in its first stage, 
or by gradual resolution, or suppuration, or by conversion into indurated tubercles. 

The syphilitic squama are hard, dull, opaque patches of thickened epidermis, 
varying from the size of a dime to a half-dollar, and raised above the surrounding 
skin by a chronic thickening of the dermis or rete-mucosum. The centres of these 
patches are often depressed, and they are of a dark brown or black color, which is 
a long time in disappearing. These squama have a tendency to excoriate and 
slightly ulcerate in the centre, which become covered by a small, dry, thick crust, 
and their surfaces are also traversed by fissures without ulceration. The dermis of 
the centre retains its depression after the cure. The squamae appear in connection 
with inflammations and ulcerations of the fauces and palate, with iritis, and the pains 
and diseases of the periosteum and bones. 

The particular treatment of these affections is confined to the administration of 
sndorifics, the decoctions already mentioned, with the carbonate of ammonia, the 
vapor bath, and mercurial fumigations. When mercurials fail, they have* yielded to 
the preparations of arsenic, or the iodide of potassium. There is scarcely any form 
of the cutaneous syphilitic diseases in which the fumigations with cinnebar may not 
be used to advantage ; and probably the best way of using them is by mixing the. 
cinnebar with wax, and moulding it into a candle. The candle thus made, and 
burned under a glass funnel, the tube of which, carrying the vapor under the bed- 
clothes, ensures the benefit of the fumigation. 

The syphilitic visiculce are very rare. The vesicles are situated upon an inflamed 
base, of a deep coppery red. They are generally accompanied by fever, inflamma- 
tion of the fauces, &c, and are succeeded by the pustular eruption. 

Antiphlogistic treatment, with the warm bath and sndorifics, is particularly indi- 
cated. 

The syphilitic pustula are characterized by an elevation of the epidermis, raised 
by a collection of pus, and are commonly placed upon a tuberculous base. Ulcera- 



152 SECONDARY SYMPTOMS. — CUTANEOUS ERUPTIONS. 

ting, they form characteristic syphilitic sores, with hard elevated edges, foul surface 
and sanious pus. They are irregular in their appearance, and may remain stationary 
until met by proper treatment. After a time their hard, raised bases assume a dark 
brown color, or coppery red. Though belonging to the secondary symptoms, pus- 
tules are sometimes developed upon the skin of the penis, pubes, scrotum, and labia, 
during the primary stage. In this case they have a red, indurated base, and soon 
change into ulcerations. 

There are generally reckoned two distinct groups of pustula, the miliary or the 
psydraceous, and the phlyzaceous. The former are small, numerous, arranged in 
clusters, and disposed to become confluent. Each pustule is an opaque white point, 
placed upon a hard, deep red or copper colored base, and when opened presents a 
small grayish excavation, which ulcerates slowly, leaving a depressed cicatrix, brown, 
or thinly encrusted. The latter division are formed separately and distinctly upon 
the skin, with hard, thick, conical bases, surrounded by a deep red, brown, or cop- 
pery areola. Ulcerating, they form sores, having thick, elevated, and excavated 
edges, secreting an offensive pus, or becoming covered with thick crusts. They re- 
main stationary or spread, and give rise to red, fungous and painful vegetations. 
These pustules are often situated over the bones nearest the surface, and after ulcer- 
ating, they spread and penetrate the periosteum and the bones, — running now into the 
tertiary symptoms, which belong to the deep seated tissues. The crusts of these 
ulcers sometimes cover the face and the greater part of the body, producing a con- 
stitutional disturbance which may terminate fatally. 

The treatment of the pustular forms of secondary syphilis, must be varied to meet 
the degree of irritation, and the particular nature which they have assumed. Low 
diet, the warm bath, anodynes and opiates, must meet antiphlogistic indications. 
If the disease is chronic, we may use the vapor bath and mercurial fumigations, and 
at this period we may administer mercury internally — the proto-iodide, the cyan- 
uret, and the syrup of baron Larrey. 

But if the patient's health is undermined, and sinking under the irritation of exten- 
sive ulcerations, we must abandon specific treatment, and resort to mild tonics, a 
generous diet, and opiates externally and internally administered. Large and pain- 
ful pustules or ulcerations may be dressed with the aqueous solution of opium, 
opium cerate, or a lotion composed of from ten to fifteen drops of hydrocyanic acid 
to the ounce of water. Chronic or indolent ulcers may be dressed with the oint- 



SECONDARY SYPHILIS. — 01 rANEOl i ERUPTIONS. L58 

ment of the proto-iodide of mercury. Washes of the solution <>f the chloride of 

lime or soda, with dustings of calomel and opium, may be used as in other ByphilitiG 
sores, according to the indications, and as iho judgment of the surgeon m,i\ direct. 

In all diseases of this kind, opiates appear to possess an excellent and almost a 
specific influence. It is certain that many patients will recover by their use alone. 
The syphilitic papula are small, hard, solid elevations upon the skin, surrounded by 
a small inflamed areola, having, frequently, ulcerations at their apices covered with 
dry incrustations. They arc disseminated over the body in groups, or disposed to 
be confluent. They are et* a deep red or copper color, have a tendency to ulcerate, 
and form hard incrustations, which leave brown, depressed cicatrices in the skin. 
Papula are found in connexion with pustules, tubercles, squamae, iritis, and almost 
all the symptoms of confirmed syphilis. 

When these papular eruptions are situated on the anus, prepuce, or vulva, and 
neighboring parts, they cause an intolerable itching, which may sometimes be allayed 
by mercurial ointment, but more frequently by solutions of sugar of lead or nitrate 
of silver. The skin may be sponged with weak solutions of the bichloride of 
mercury, while the treatment proceeds for the general disease. In cases of high 
irritation and fever, antiphlogistic measures must be resorted to. 

The syphilitic tuberculse of the skin, are deep-seated, solid, circumscribed eleva- 
tions, containing neither lymph nor pus, and are larger and better defined than 
papula?. They are isolated or grouped ; are of a shining red, livid, or brown 
color, with a dark red or coppery areola. These tubercles have a tendency to 
ulcerate and form excavated sores with elevated edges, a foul surface, and offensive 
pus, which, drying, leave dark or gray scabs. The syphilitic tubercle seems to be 
the connecting link between the secondary symptoms and the tertiary, attacking 
the deep seated tissues, and being found in the centre of the brain and in the 
heart. 

There is a species called the flat tubercle, or tuberculous pustule. It is smooth and 
flat on the surface, appears on the scrotum, labia, the vicinity of the anus or mammce. 
They are from a dime to a quarter of a dollar in size, and are not disposed to 
ulcerate. 

The more common tubercle, is scattered over the body slightly or in patches, from 
the size of a pea to that of a large hazle-nut. They arc usually situated on the 
anterior part of the chest, the abdomen, on the neck, or the insides of the arms. 



PLATE XII., BIS. 



POLYMORPHOUS VEGETATIONS. 



There was nothing in the health of the family of this patient, that could lead us to infer 
that the disease that existed in him, could have been inherited from his parents. For his 
appearance, he was above the middle height, his hair was chesnut, and his skin quite white. 
He pretended never to have contracted the venereal affection, or, at least, it had never been 
perceived. In this respect, he was subjected to interrogatories the most complete, and 
an examination the most minute. During the last ten months, or longer, he had had no 
sexual intercourse, and did not remember that he had been exposed to any impure contact. 
His answers, frankly expressed, seemed to permit no accusation of connexion a prepostera 
venere. There was neither to be found on his genital organs nor other parts, the least trace 
that it was possible to connect with the cicatrice of a primitive ulcer. Neither the skin nor 
the mucous membrane, exhibited any secondary eruption, and tissues as deep as the osse- 
ous system presented no symptom of a syphilitic affection. In short, all the organism 
showed itself to be in a healthy state, save the affection that we proceed to describe. 

The patient could not indicate in a precise manner the period when the numerous vege- 
tations that were seated round about his anus, began to be developed. He remembered, 
however, that, in the course of the month of May, in consequence of labor very fatiguing, 
and of much running, he felt a lively itching at the anus, the folds of which were tumified. 
This state excited an imperious desire to scratch, so far as, often, to produce excoriations. 

No treatment was adopted ; and the means of cleanliness were even neglected, as the 
patient declared to us that he had not taken a bath for ten years. Nevertheless, the itch- 
ings disappeared after a score of days ; or, at least, they changed in their nature, and be- 
came much less intense. 

Such were the precursory symptoms of the actual affection. Very small granulations 
were at first shown on the sides of the anus ; then the eruption increased, step by step, 
with a constant progress, until it is now developed into a mass of vegetations, at all times 
bathed by a muco-purulent secretion, that the slightest touch of the diseased parts will 
render sanious. 

We can, also, see here the characters assigned to different varieties of vegetations. Some, 
at the commencement, offer simple isolated granulations, due to the extroversion of mucous 

154 



PI ill •'> 




i:\ri. \\ v HOW OF PLi I B ml, BIS. * IA5 

or cutaneous follicles ; others, more advanced) are themselves covered with granulati 
mor ■ projecting, and most of them, arc agglomerated in loi ■ or deci- 

dedbj prediculated, and sustained by a single stalk, in some in itance ■ quhfc thick, beai 
numerous branches. On the buttocks, and in the parts where they are freely developed, tiny 
represent very well the cauliflower, whilst in tin' immediate vicinity of the anus, pre ed 
be lateral masses, they have the form of the comb of a cock, or of raspberries* We 
also, that their consistence and the thickness of the epidermis that covers them varies, 
irding as they are more or less exposed to the drying action of the air. <)n the fold 
t ho anus, they are humid, friable, bleed easily, and are bathed by an abundant secretion of pus 
and mucus. But, in proportion as they are distant from the central parts, they are paler, 
with a surface less granulated, and are not so easily fretted. On the external Limits, some 
portions have a consistence and dryness, scarcely differing from that of the contiguous skin. 

December 97th. There was much irritation in the diseased parts. Dressed with the solu- 
tion of opium, and restricted the patient's diet. 

January 3d. The vegetations showed more inflammatory super-excitation, but their volume 
appeared to follow the regular increase. The same dressings; we gave the fourth of the 
alimentary allowance. 

January 4th. The vegetations were removed with the aid of the scissors ; after which, 
compresses were applied, soaked with cold water. Diet low. 

January 6th. We cut off some small vegetations that rested in the folds of the anus. Con- 
tinued the applications of cold water, and gave half an allowance of food. 

January 12th. All is cicatrized on the skin of the circumference of the anus. Water 
dressings continued. Three-fourths of an allowance of food. 

January 1.7th. Cured. 



EXPLANATION OF PLATE XII., BIS. 

The patient is placed in such a manner that the separation of the buttocks, allows us to 
see at one view the vegetations, cleansed from the muco-purulent matter that covered 
them. On the median line, in the neighborhood of the anus, restrained in their develop- 
ment, pressed by the lateral masses, and but little exposed to the contact of the air, they 
show themselves flattened, and in some points, under the form of cock's-combs. Their 
surface is there finely granulated, colored a lively red, and constantly bathed by an abun- 
dant muco-purulcut secretion. In many places the epidermis is wanting. 

At some distance from the parts that have been described, the vegetations have a paler 
tint, the granulations are more developed, and covered with an epidermis more resisting. 
Finallv, the elements that form the groups can be easily distinguished. Towards the 
coccygeal region, we can equally see the pedicles that distinguish the main stalks from the 
radiating branches. On the right side and upper part, we remark, particularly, forms which 
resemble the cauliflower; while on the same side, near the scrotum, they have the appear- 
ance of sessile plates. On the left are some portions of vegetating tissue resembling very 
much strawberries or raspberries. 




156 " SECONDARY SYPHILIS. — CUTANEOUS ERUPTIONS. 

Another variety makes its appearance on the alee and lobule of the nose, or on the 
forehead ; or it may appear on the tongue, or the neck of the uterus. In these 
situations it is sometimes taken for a cancerous affection, and should be subjected to 
a very careful diagnosis. 

Assembled in circular groups, these tubercles are denominated syphilitic herpes. 
They are commonly complicated with a scrofulous, scorbutic, or herpetic diathesis ; 
their progress is slow and without much pain, and they gradually increase in size, 
till they soften and ulcerate. This is the most formidable of all the secondary 
symptoms, produces great deformity, and is difficult to cure. 

Resolution is the first object in the treatment of these tubercles, which, before the 
softening or commencement of ulceration, may be obtained in some cases by the 
exhibition of the iodide of mercury, with the iodide of potassium. If the general 
health of the patient presents no counter-indications, the treatment may be com- 
menced by giving a pill containing one grain of the mercury, combined with conium 
or opium, and with a solution of the iodide of potassium, in doses of ten grains a 
day. On the fifth day the dose of the mercury may be doubled, and that of the 
potassium increased. It is not generally necessary to augment the mercury further, 
or continue it long, and the treatment is completed by the iodide of potassium. 
Resolution is also effected by mercurial fumigations, alternating with baths. Sarsa- 
parilla may be combined with, the iodide of potassium, frequently, with the happiest 
results. Cooling lotions, and local applications of the solution of opium poultices, 
fomentations with the infusion of poppy and henbane, and the employment of 
leeches at a little distance from the tubercle, are recommended by high authorities. 

When the inflammation is subdued, and the tubercles remain indolent, mercurial 
frictions and stimulating washes may be of service. A local antiphlogistic treatment 
must be pursued, whatever be the internal treatment, as long as any inflammation 
is present. In the ulcerative stages of tubercles, the remedies do not differ from 
those that are useful in primary chancre. A solution of nitrate of mercury in nitric 
acid applied to the surface of the ulcers, has been found a very useful caustic. In 
these stages, the various forms of mercury, the iodide of potassium, decoctions of 
Feltz and Zittman, liquor arsenicalis, arseniate of soda, antimony, or the nitro-muri- 
atic acid, may be employed at discretion, for one will often succeed when another 
fails — arsenic may cure where mercury has produced no apparent effect, and some- 
times all alike seem useless. In such cases the patient may be removed to a fresh 



SECONDARY SYMPTOMS.— CUTANEOUS ERUPTIONS. 157 

atmosphere, or a more genial climate, his genera] health must be carefully attended 
to, ami the treatment resumed under more favorable auspices. 

Constitutional syphilitic ulcerations, not preceded by pustules or tubercles, are 

very rare ; but they sometimes appear preceded only by a Blighl itching and redness 
of the skin, to which ulceration immediately succeeds. They have the Btrongly 

marked syphilitic characteristics. Usually they are situated about the nose, edges 

of the mouth, eyelids, ears, mastoidean region, and arc common upon the mamma . 
Dear the umbilicus, in the axillse, the groins, and round the edges of the nails. 
They also make their appearance in the form of fissures, where the folds 
of the skin favor their production. These arc seen on the scrotum, around the 
anus, the umbilicus, the commissures of the fingers and toes, the folds of the eyelids, 
the lips, the palms of the hands, and the soles of the feet. The local and general 
treatment do not differ from that of other syphilitic ulcers just described. 

Vegetations or excrescences, form the last of the diseases of the skin belonging to 
the class of secondary symptoms. They are of various forms and appearances, and 
show themselves upon the skin and edges- of the mucous membranes. They have 
been divided into three varieties : the horny and inorganic excrescences of the epi- 
dermis ; the ccllulo-vascular, composed chiefly of blood-vessels, growing from the 
surface of mucous membranes, and even from the skin itself. They arise from long 
continued irritation and inflammation, and are found on the surface of the glans 
and prepuce, after protracted balanitis or posthitis, about the anus, and upon cica- 
trices or the surfaces of old constitutional ulcers of the skin. 

The inorganic forms, called venereal warts, may be removed by the knife or liga- 
ture, or by touching them with nitric acid, being careful to avoid the healthy parts. 
Where the vegetations are vascular, large and inflamed, leeches are of service and 
after inflammation is subdued, the knife or scissors may be selected for their 
removal; but if painful and inflamed, the operation is likely to extend the disease, 
and give rise to larger growths. The muriate of gold, in the form of ointment or 
solution, is considered as one of the best local applications ; but we may use the 
aqueous solution of opium to subdue pain, and the mercurial ointment if they are 
indolent. If they are destroyed with caustic, the nitrate of silver is perhaps as good 
as any other. When these vegetations arc clearly syphilitic, constitutional treat- 
ment and mercurial fumigations are of great service. 

A kind of excrescence, called condyloma, or crista-galli, sometimes appears around 



158 SECONDARY SYMPTOMS. — CUTANEOUS ERUPTIONS. 

the anus, or between the glans and prepuce, or on the external part of the female 
organs, which consists of a development of the skin or mucous membrane, and the 
subjacent cellular tissue, forming a soft, flattened, elongated, indolent tumor, which 
is sometimes red, painful, and excoriated, secreting an offensive pus, and at others 
quite indolent. They may depend upon an ulcer, situated in the folds of the inte- 
gument or the mucous membrane. The inflammation, if any, must be subdued, and 
they may then be treated with frictions of mercurial ointment, or the muriate of gold. 
Their treatment generally is the same as that of an indurated chancre, and in some 
cases their excision by the scissors or scalpel is demanded, in consequence of their 
situation interfering with certain necessary functions of nature. 

There is one form of cutaneous syphilitic disease, that of mucous tubercles, or 
papulae, for which Ricord prescribes the following local treatment, to which, he says, 
they yield with astonishing celerity, whether situated in the anus, vulva, groin, be- 
tween the toes, at the umbilicus, or axilla. While the general treatment is such as 
is required for a constitutional affection, the diseased parts are to be washed, if not 
indurated, with pure chloride of soda, or if indurated or irritated, with the chloride 
diluted, so as to produce a tingling without pain. After these washings, twice a day, 
the diseased parts are to be sprinkled with calomel. Eight or ten days of this treat- 
ment will cause enormous masses of these eruptions to disappear. 



s 









sm^. 






PLATE XIII. 

IMPETIGENOUS TUBERCULO-CRUSTACEA : RELAPSE OF SECONDARY 

SYMPTOMS ; SLOW FORM. 



ULCERATED IMPETIGENOUS SYPHILIS. (VARD2TY OF IMPETIGO 

RODENS.) 

CASE FIRST. 

This patient, 32 years of age, born of healthy parents, with a strong constitution, vacci- 
nated, and married, had always enjoyed good health until two years ago, when he con- 
tracted, for the first time, with a woman who was not his wife, an urethral blenorrhagia, 
which was followed by an acute epididymitis. 

Antiphlogistics and balsams, (copaiba and cubebs,) effected, in about three months, the 
cure of these accidents without any manifest complication. 

Six months after the cure, and, this time, without hiving had other connexions than those 
he had with his wife, he perceived an ulceration at the base of the glans. The diseased 
part was hard, indolent, and furnished but very little pus. In the groins were many en- 
gorgements that occasioned no pain, and which afterwards disappeared without suppuration. 

For these accidents the patient was under treatment during three months. He took 
mecurial pills, of which he knew not the formula. 

Six weeks after the commencement of the ulceration of the penis, pains of the head su- 
pervened, particularly at night ; subsequently, appeared a swelling of the posterior cervical 
ganglions, accompanied with great pain in the movements of the neck. After severe fatigue, 
the patient observed, all at once, a crustaceous eruption develope itself on the scalp. An 
alopecia, partial and disseminated ; some nocturnal pains of the members, that he took for 
rheumatism, afterwards manifested themselves. 

These accidents were treated with bitter drinks, and the proto-iodide of mercury in pills , 

159 



160 EXPLANATION OF PLATE XIII. 

in successive closes of one, two, and three grains daily. They were augmented every eight 
days by one additional grain. 

After the last dose, followed a stomatitis, which forced the patient to suspend for a time, 
the employment of the mercurial pills. He was then subjected to the use of the nitric lem- 
onade ; took, every morning, four scruples of sulphur, mixed with honey under the form of 
a confection. At the same time he used a gargle, sharpened with the hydrochloric acid. 

Ten days of this medication sufficed to remove the mercurial accidents, and it was then 
possible to resume the mercurial treatment, which was continued during two months, when 
every symptom had disappeared. 

The patient was convinced that all the symptoms which have been enumerated, ought to 
be attributed to the gonorrhoea that he had formerly had ; and, still more, he accused him- 
self with having communicated to his wife the disease that we are going to describe, and of 
which the following are the antecedents : 

Madam was born of healthy parents, aged 29, and in her infancy had had small pox j 
since then she had enjoyed good health ; nevertheless, before the occurrence of the disease 
for which she came under our observation, she -was for some time affected with a chronic 
and purulent catarrh of the uterus. She had had six children. 

Eight days after having had many connexions with a man who was not her husband, she 
felt, in urinating, sharp smarting, and perceived an abrasion of one of the nymphae. To 
this abrasion succeeded an ulceration, that increased little by little, the base of which was 
indurated. After this appeared an engorgement of the neighboring groin. For these first 
symptoms, the patient had never consulted any doctor ; they were cured by simple means. 

Three months later, pains of the throat supervened, and, successively, pimples on the 
vulva were developed. An engorgement of the cervical ganglions next occurred, and crusts 
appeared on the scalp. 

When the patient came to consult us, these accidents had lasted for six months, and she 
had eruptive spots on the amygdalge and on the vulva ; the latter were confluent, much de- 
veloped, and almost vegetating. 

All these symptoms disappeared in about three months, under the influence of chloride 
lotions, calomel powder, and pills of the proto-iodide of mercury. 

Madam concealed from her husband all the primitive accidents that she had had ; and 
she began to complain only when the secondary symptoms no longer permitted her to dis- 
semble. Then she accused her husband with having been the author of her malady ; this, 
however, was untrue, for, from her own confessions, that we have related above, the ulcera- 
tion that the husband had on the penis, made its appearance eight days subsequently to the 
time of the appearance of her own. 

But let us return to the history of the husband. Six months since he thought himself 
cured, when he experienced during the night, pains of the two tibial bones. On different 
points of the face, appeared dark red spots ; they soon became projecting, round, and were 
all covered with yellowish crusts, shell-like and rugous. After their fall, tubercles were 
seen, the surfaces of which were slightly ulcerated. 

This tuberculo-impetigenous eruption, disseminated in some points, and grouped in others, 
had neither been preceded by nor accompanied with fever, but it had often occasioned 
quite lively itching. 



EXPLANATION OF PLATE XIII. 161 

The patient was subjected to the use of the ptisan of dulcamara ; li<; took pills of the 
proto-iodide of mercury, the strongest dose of which was three grains a day. Every night 
a friction was made on the eruption, with the following ointment: 

ly.. While precipitate, 4 parts. 
Sulphur cerate, 30 parts. 

Under the influence of this treatment, the crusts became detached, and were not repro- 
duced. Little by little resolution of the tubercles was effected ; but those that were grouped 
on the chin had vegetated, and it was necessary to cauterize them with the liquid acid 
nitrate of mercury. 



SECOND CASE. 



This patient, now 70 years of age, in his infancy and up to the age of twelve, had been 
excessively meagre and pallid, but without characterized disease. At five years he had on 
the left thigh an abscess, probably scrofulous. A short time after he experienced consider- 
able pain in the coxo-femoral articulation. Resisting the action of the bitters and repeated 
antiphlogistic treatment, this articular pain has persisted to the present day. 

For about the last fifty years, he has been tormented by a sebaceous acne of the face, 
and by a black pityriasis in extended patches on the shoulders and on the back. 

For two years he had sexual connexion with a woman who, previously, had been for ten 
years his mistress, but whom he had lost sight of for a long time. 

Eight days after these connexions, he perceived the existence of a chancre on the pre- 
puce. It became indurated, and it was then that he presented himself, the 8th of April, 
1842, and received the following treatment: 

The ptisan of soap ; pills of the proto-iodide of mercury, in the dose of one to two grains 
daily. 

A little erythema that supervened in the throat, necessitated, besides, the employment of 
an alum gargle. Six weeks of this treatment effected a cure, without any other manifesta- 
tion of secondary syphilitic accidents, except the persistence of the induration of the 
chancre. 

The 14th of February, 1843, the patient returned with an eruption that was seated on the 
upper lip andthe right ala of the nose. This eruption of the impetigenous form, commenced 
by a small pimple situated near the nostril. This pimple was soon covered with crusts, at 
first yellow, and then greenish, shell-like and rugous. Soon other pimples, of the same na- 
ture, appeared around it, and formed a crustaceous patch about all the lip and nostril. In 
this point the skin was thick, but it presented no cedemato-erysipelatous base, such as often 
accompanies common impetigo. 

The eruption was nicely circumscribed by healthy skin, without any inflammatory circle. 
The crustaceous exudation seemed to be more extended than the surface that furnished it. 



162 EXPLANATION OF PLATE XIII. 

At the point of junction of the lip with the nose, it was thickened and honey-comb like. It 
ended by falling off and exposing an ulceration, which, penetrating into the nasal fossa, had 
detached the lip from the ala of the nose. This eruptiou had not been accompanied nor 
preceded by fever, and had never caused any itching nor much pain. 

The following is the treatment under which he was placed : 

There was applied on the diseased parts, lint, moistened with a liquid prepared as below. 

fy. Aquae destill. part. 200. 
Tinct. Iodinii, part. 6. 
Potassii Iodidi, part. £. 

Every day were administered two-thirds of a grain of the iodide of potassium, in three 
doses, taken in the ptisan of dulcamara. One pill of the proto-iodide of mercury daily ; 
then two, until the treatment was completed. He was cured by the 28th of March, 1843. 

At the beginning of January, 1845, he had experienced no relapse. 

This patient had never had engorgements of the cervical ganglions, and the fact deserves 
to be stated ; for this engorgement, that is sometimes wanting, becomes more and more rare 
after the age of fifty. 



EXPLANATION OF PLATE XIII. 

Figure 1. Impetigenous tuberculo-crustacea ; relapse of secondary accidents. 

Figure 2. Spots of the termination of the eruption represented in Figure 1. We see on the 
chin a patch that has succeeded to three tubercles grouped together below the under lip. 

Figure 3. Impetigenous pustulo-crustaceous eruptions, ulcerated, (variety of Impetigo 
rodens). A part of the eruption is still covered with crusts ; but about the ala of the nose 
they have fallen off, and exposed an ulceration which has extended up in the nostril. 



CHAPTER X. 

SECONDARY SYMPTOMS. — ULCERATIONS, &c. 

Of the tonsils, mouth, and throat. — The premonitory general symptoms. — The local. — Tonsil most lia- 
ble to bo attacked first. — Sometimes the ulcer resembles cancer. — Many varieties of ulcer. — General 
sloughing alarming : the treatment necessary. — Local treatment, mainly gargles and caustic. The 
general treatment the same as in the primary disease. — Iritis : symptoms. — General and local anti- 
phlogistic treatment. — Blisters. Mercurial dressings. Belladonna. — Syphilitic Sarcocele : symp- 
toms : treatment. — Falling off of the hair and nails : treatment. — General advice upon practice. 

In a considerable proportion of cases, ulcerations of the tonsils, mouth, and throat, 
are the first of the constitutional symptoms which manifest themselves. They are 
preceded generally by languor in the evening, indisposition to take active exercise, 
fugitive pains in the shoulders and legs, and unrefreshing sleep. These fugitive 
pains cease with the appearance of the ulceration. 

The local symptoms which precede the venereal sore throat, are at first a slight 
uneasiness in swallowing, which increases in a few days to painfulness ; a dryness 
in the throat on awaking, and a peculiar painfulness attending the effort to swallow 
saliva — and, finally, a slight swelling and tenderness are discovered externally, on 
the site of the tonsil. These symptoms, however, do not strongly differ from those 
of an ordinary sore throat ; but we may generally be guided by other circumstances, 
and especially, the fact of the primary symptoms having previously existed. 

On inspecting the throat, we find one tonsil, or both, with increased redness, 
swollen, and when the disease has proceeded so far, an ulcer, which Hunter de- 
scribes as " a fair loss of substance, part being dug out, as it were, from the body 
of the tonsil, with undermined edges : this is commonly very foul, having white, 
thick matter adhering to it like a slough, which cannot be washed away." This, 
though regarded as the peculiar type of the syphilitic sore throat, is not an absolute 

163 



164 SECONDARY SYMPTOMS. — ULCERATIONS, &c. 

indication. An ulcer, closely resembling this may be non-specific, and on the other 
hand the truly syphilitic affections of the throat and surrounding parts, present a 
great variety of appearances. 

Though the tonsil is the part most liable to be first attacked in the venereal ulcera- 
tion, yet we may find it in the back part of the pharynx, concealed from view by the 
velum-palati, where it may be seen by depressing the tongue and raising the palate 
with a proper instrument. A speculum for examining diseases of the throat should 
be in the hands of every surgeon. 

An ulcer of the pharynx may also be situated below the level of the base of the 
tongue, and in this case there is danger of its extending still lower, so as to produce 
extreme suffering and even death, from the gradual destruction of the important or- 
gans here situated. 

A very painful situation of these ulcers, is at the union of the anterior palatine arch 
with the tongue. In this case there is not only painful swallowing, but a pain shoots 
up one side of the head and face. Or the ulcer may be found at any point about the 
base of the tongue. 

In other cases the ulcer may be found high up behind the velum, in the angle of 
the pharynx. An ulcer is sometimes, though rarely, situated on the posterior surface 
of the velum itself, in which case it is indicated by swelling, redness, and may be 
ascertained by passing a probe with lint, behind, when, if there be an ulcer, the lint 
will exhibit the discharge. 

We have other syphilitic ulcerations and affections of the tongue and lips, some 
of which are not easy to distinguish from cancer, and which the cancer doctors cure 
by the administration of mercury, thus gaining great credit for their skill in curing a 
disease which never had existence. The varieties of venereal ulcerations and fissures, 
to which these parts are liable, are very considerable, but they do not require a par- 
ticular description, or indications of treatment, as we must be governed more by 
general rules than particular local symptoms. 

The strongly marked Hunterian ulcer, already described, may be considered as 
the one extreme of the venereal ulcers of these parts ; the other extreme is a slight 
superficial ulceration, like an apthous ulcer, with a slight swelling, and some sur- 
rounding redness. It creeps along from place to place, and, unless seized by phage- 
dena or sloughing, is of a mild and indolent character. Every shade may be found 
between these extreme varieties. 



SECONDARY SYMPTOMS. — ULCERATIONS, fa L65 

One of tlu 1 most alarming aspects which 1 1 1 * ^ venerea] sore throat can assume, is 
that of a general sloughing ulceration, involving both tonsils, the entire velum, and 
the back of the pharynx, which all seem converted into a pnltaceous mass, or cn- 
tirely covered with a sofl slough, which adheres tenaciously to the surface. The 
patient can scarcely swallow the blandest fluid ; a ropy saliva flows constantly from 
his mouth by day, and when he sleeps at night threatens him with suffocation. The 
general health gives way under these irritations; his strength is prostrated, he is ex- 
tremely emaciated, and has a high grade of hectic fever ; a most pitiable and alarm- 
ing condition, and requiring the soundest judgment for its treatment. The system 
must be sustained and strengthened, and the ulceration arrested by topical applica- 
tions, while mercury must be cautiously administered. 

The local treatment of ulcers of the throat and mouth, consists almost entirely of 
gargles and caustic. Gargles of cicuta and sage, and of corrosive sublimate may 
be administered with advantage. Cauterization may be effected with a strong so- 
lution of the nitrate of silver, or with the acid nitrate of mercury, or as Colles re- 
commends, the muriate of antimony. Cauterizing washes may be applied in all the 
situations we have heretofore described, by means of a piece of lint firmly attached 
to the end of an aneurism needle, or any similar instrument; but in such cases the 
lint containing the caustic must be well secured against removal. 

In the phagedenic forms of these ulcers, opiated and other narcotic gargles produce 
a good effect, and when the inflammation has abated, cauterizations with hydrochlo- 
ric acid and gargles of bark are to be ranked among the best modes of treatment. 

If the ulcerations of the pharynx proceed so as to threaten the entire destruction 
of the uvula, it should be removed, as its separation in sleep might occasion serious 
difficulty, by its falling on the glottis. 

Aside from the general constitutional treatment, already very fully treated of, the 
local is to be governed by much the same principles as those laid down in regard to 
the primary symptoms, only, as the local succeeds the general infection, nothing like 
an abortive treatment can be thought of. Our first object must be to check the gene- 
ral disease by the prompt administration of the only medicine upon which we can 
rely with any confidence, and upon the success of which mainly depends the patient's 
chances of recovery ; or, at all events, of a speedy and perfect cure. 

When the ulcerations attack the roof of the mouth, or the interior of the nose, 
they often uncover the thin and very delicate bones of these parts, which exposure 
of surface may cause osteitis, terminating in caries, and sometimes in necrosis. 



166 SECONDARY SYMPTOMS. — ULCERATIONS, &c. 

The bones in these cases are not the seat of the disease apparently. At least they 
yield to treatment and heal much more readily than in the tertiary form, where the 
bones are the seat of the disease. Important disfigurements may be thus produced, 
some of which, however, surgical art has found means to remedy, though medical 
skill may not always prevent them. 

Among the secondary symptoms, is the syphilitic iritis, which most frequently 
accompanies the cutaneous eruptions. It is often characterized by an egg-shaped 
deformity of the pupil, which has its longest diameter running downward and out- 
ward, and an alteration of the color of the iris, which has sometimes excrescences 
on its pupillary margin and anterior surface. The chambers of the eye are often 
filled with albuminous effusions ; these may be absorbed, or they may form adhe- 
sions, which restrict the movements of the pupil, or cause the formation of pseudo 
cataracts. The syphilitic opthalmia does not essentially differ in its symptoms from 
that occasioned by non-specific inflammation. 

The treatment of this affection must be energetic. The inflammation is first to 
be subdued by a general and local antiphlogistic treatment, the latter consisting in 
the application of leeches to the temples and mastoid processes. As soon as the 
inflammation and pain have been subdued, blisters are to be applied to the neck, 
temples and over the orbita. The suppuration of the blister on the neck is to be 
kept up, while those around the eye are to be dressed with mercurial ointment, and 
when they have dried up, the blisters are to be renewed and treated in the same 
manner. The mercurial ointment may also be applied below and around the eye, 
while the eye itself is to be treated with its own peculiar sedative — belladonna, by 
frictions around the orbit, up the nostrils, and by its internal administration in combi- 
nation with mercury, the proto-iodide of which is probably, in this form of disease, 
the best preparation. 

Syphilitic Sarcocele, or swelling of the testicle, is a rare symptom of the second- 
ary affection. The testicle grows indurated, increases in size, and becomes pear- 
shaped. This disease is often accompanied or preceded by pains in the loins, and 
the induration may affect the cord, or the epididymis, as well as the testicle itself. 
Though the general treatment may be sufficient, alone, to effect the cure, it may be 
accelerated by the application of five or six leeches every six or eight days along 
the cord, and the scrotum may be enveloped with half a drachm of strong mercurial 
ointment, and if painful, covered with an emollient cataplasm. If the patient cannot 
keep quiet and recumbent, we may resort to a mercurial plaster and compression. 



SECONDARY SYMPTOMS.— ULCERATIONS, fco. L67 

The falling oil* of the hair and the nails arc among the secondary symptoms 

which occasionally present themselves. The hair is loosed by some cutaneous 
affection of the scalp; the nails fall out from ulcerations around their matrices. 

The most important treatment is that of the disease — the special or local, that 
which belongs to the particular cause. The head must be shaved, and the scalp 
robbed with stimulants, ointment of proto-iodide of mercury, or tincture of cantha- 
rides diluted with alcohol. The nails must not be pulled out. We may let them fall 
off, and treat the matrix as for mucous tubercles. 

I have not attempted to give a detail of particular cases, with the progressive treat- 
ment. It would be of very little service, as no two cases present precisely the same 
indications. The general principles of treatment, and their adaptation to certain 
symptoms, stages, and forms of the disease, is all that can be accomplished with any 
benefit. 

Syphilis is the very last disease, the treatment of which should be confided to 
incompetent hands — how deplorable is the fact that it is the very one on which 
quackery most fattens and thrives! 

And now as I am about to close the treatment of secondary syphilis, permit me 
to give you a little advice, which may at some future time be of great service. 

Never allow yourselves to ride a hobby-horse ; for when you least expect it he will 
throw vou, and if in the fall you are not killed, you may be maimed for life, and bear 
about you the marks of a betrayed confidence in your favorite hobby. You must 
remember that in our profession, there are but very few, if any, perfect specifics, and 
we must, therefore, as careful physicians, jealous of our own character, look well to 
it, that we do not commit any palpable errors. Steer clear of quicksands, shoals, and 
breakers. In the treatment of this sometimes obstinate disease, we must have re- 
course, from time to time, as the case may require, to all the best remedies which 
have sooner or later been discovered, and recommended by the enterprising in our 
profession. For, after all, we are obliged to confess, however humiliating it may be 
to the man of learning, that there is too much conjecture and uncertainty in the art 
of medicine, for when one remedy does not succeed, we must resort to others. But 
how often do all our efforts fail. When the ordinary remedies are exhausted, I have 
found sometimes the muriated tincture of gold, or the chloride of gold and so- 
dium, produce the best effects, and rapidly promote a cure. [See p. 1147, Dispensa- 
tory, U. S.] 






PLATE I. 



[DESCRIPTION OF FRONTISPIECE.] 



TUBERCULOUS SYPHILIS : IRITIS : SECONDARY SYMPTOMS. 



This patient, 21 years of age, with a fair skin, blonde hair, lymphatic appearance, and 
delicate constitution, contracted, at the age of eighteen years, a chancre from a public 
woman. He had never had syphilis before, and he had not had since any other primitive 
accident. The chancre existed on the edge of the prepuce ; it suppurated for two months, 
and was dressed with nothing except sugar of lead cerate. 

In the course of the month that followed the cicatrization of the chancre, he was attacked 
with a syphilitic roseola, complicated with an iritis of the same nature, but very slight. 

When he came under our observation, his eye was in good condition, but the skin of the 
body presented numerous red spots ; the hair fell out, and the epidermis of the scalp formed 
an abundant pityriasis. Prescribed pills of the proto-iodide of mercury, fumigations of 
cinnabar, and sarsaparilla. 

On the 18th of October there was seen, on different points of the skin of the face, the 
trunk and the members, succeeding to exanthematous spots, a thickening of the tissues, 
which, by degrees, took the character of cherry-red tubercles, projecting, round and 
hard, but without alteration in the color of the surrounding skin ; some, notwithstanding, 
were encircled with an areola of a coppery red, and around others there was a papulous 
ring which gave to the eruption the form of an iris. 

At the same time that the tuberculous eruption developed itself, the left e3 r e, which had 
been affected with an erythematous iritis, became the seat of a most grave affection ; the 
vessels of the conjunctiva and sclerotica were deeply injected, and a brownish circle was 
drawn around the cornea. The color of the iris had a copper tint, and the extent of the 
anterior chamber seemed diminished in consequence of the swelling of the iris, on the infe- 
rior part of which was developed a tumor of a deep red color, projecting, touching the pos- 
terior face of the cornea, and analogous to the cutaneous tubercles. The pupil was deformed 
in a manner that has been regarded peculiar to syphilitic iritis : that is to say, offering an 
illipse, the great axis of which was directed from the top to the bottom, and from within 

168 



EXPLANATION OF PL UK I.— FRONT I SI' I MCE. 169 

outwards i it bad lost much of its mobility, and remained habitually a little more dilated 
than thai of the opposite eye. There was not much photophobia, but thi re exi ted a ranra- 

orbital pain, with nocturnal exacerbations. 

The patieni was Created with pills of the proto-iodide of mercuryj to each of which was 

added a grain of the powder of the Leaves of belladonna. Frictions were made around the. 
orbit, with an ointment composed of equal parts of the extract of belladonna and mercurial 
ointment. 

Towards the end oi' November the eve was perfectly (aired. The tubercle of the iris was 
completely absorbed; the pupil had recovered its form and mobility. 

Touching tlu- cutaneous tubercles, they were all terminated by resolution; some with 
desquamation oC the epidermis, and the persistence, for a greater or less time, of a white 
border. To these tubercles succeeded depressed cicatrices, which maintained, for a long 
tan \ a deep brown tint. After the iritis had yielded, we ceased from the use of belladonna, 
and resumed the cinnabar fumigations, which had been suspended during the whole course 
of the disease of the eye. The patient was dismissed as cured on the 8th of January. 

A month afterwards, pustules ulcerating the skin with great rapidity, appeared on differ- 
ent points of the body. The patient returned for treatment on the. 5th of March. 

The pustules commenced as furuncles, by a large induration, painful and red. The sum- 
mit of the tumor suppurated; soon all the base of the pustule ulcerated, and increased each 
day both in size and depth. In April an ulceration appeared on the face. 

For two months the sores were dressed with a solution of iodine. Each day he took a 
pill, containing one grain of the proto-iodide of mercury, and two-thirds of a grain of the 
iodide of potassium in solution. On the 5th of May, he left cured : some of the cicatrices 
were red and others violet. 

The cure lasted but a month. New and deep ulcerations, with a gray and bleeding base, 
were formed with extreme rapidity, chiefly on the shoulders, the arm, and the inferior 
extremities. 

He was subjected to a new mercurial treatment with the proto-iodide pills. He had the 
baths of Bareges, alcaline baths and bitter diet-drink. His sores were cicatrized in about 
two months, but he remained under treatment for three months, and at the end of Septem- 
ber was discharged. 

This new cure continued for only fifteen days. He returned on the 15th of October with 
a large ulceration on the scalp at the top of the forehead, and with osteocopic pains in each 
tibia, where were presented, in their upper third, slightly projecting tumors. Treated for 
two months with the iodide of potassium, pills of the proto-iodide of mercury, "bitter drinks, 
and alkaline baths. 

On the 2Sth of January he left cured of his ulcerations, but, during this last period, the 
lateral cervical ganglions were engorged as if they were scrofulous. All the morbid action 
appeared to concentrate itself on these glands, during seven or eight months; they became 
enormous ; the neck, transversely, was extraordinarily large. In the month of August he 
entered the hospital, and was under the care of a distinguished physician, who treated him 
with iodine potions and baths for two months and a half, when he left in the same condi- 
tion as that in which he entered. 

In the month of November, a mucous discharge, thick and fetid, commenced from the nose. 



170 EXPLANATION OF PLATE I.— FRONTISPIECE. 

In December the arch of the palate became bent, painful and red, and a perforation took 
place on a level with the tumor, on the 25th of the month. In January debris of bone came 
away through the perforation. There were recognised,, easily, in this debris, the vomer and 
the perpendicular plate of the ethmoid. 

An abundant suppuration was discharged, from this time, by the mouth. On the 19th of 
January, he applied for treatment, in the following state : 

Emaciation extreme, lateral glands of the neck forming, on each side, an oblong tumor, 
reaching from the lobule of the ear to the middle of the neck, and as large as the shut hand. 

The perforation of the palate extended from the posterior part of the superior maxillary 
arch to the palatine bone, and permitted the introduction of the index finger. 

The sides of the perforation were red, suppurating and painful ; the secretion of mucus 
was abundant, and mixed with pus coming from the perforation. There was a want of ap- 
petite, white tongue, a fever every evening prolonged through the greater part of the night,, 
considerable weakness, and an impossibility of leaving the bed. 

The disease made no sensible progress during the months of February and March., but 
the patient, nevertheless, continued very feeble. 

Towards the 15th of April, the fever became continued, but was increased in the evening. 

On the 28th of April, it increased with a marked shivering ; and also on the next day- 
The following days there were many chills in the twenty-four hours ; a considerable heat, 
with copious sweating, succeeded to the shivering ; diarrhoea supervened, and the patient 
succumbed after one of these febrile exacerbations, in much agony, the 4th of May, nearly 
three years after the original attack. 

During the last period, the state of the patient would not allow active medicine to be ad- 
ministered to him. 

Autopsy twenty-four hours after death. 

The palatine arch had a large perforation ; the palatine apophysis of the superior maxilla, 
the palatine bone in its horizontal portion, the entire vomer, and the vertical plate of the 
ethmoid were destroyed. The maxillary apophysis was necrosed in an extent greater than 
the perforation, and if the patient had lived some months longer, all the osseous parts that 
formed the palatine arch would have been destroyed. 

The tumor of the right tibia seemed more projecting than that of the left : after the dis- 
section of the skin, we raised up the periosteum, which was thickened, white, and more 
difficult to separate from the osseous tissues than in the healthy parts ; but the thickening 
was not considerable, and did not exist over a space larger than a half-dime piece. The 
thickening of the periosteum was continuous with an analogous alteration of the aponeurosis 
that enveloped the muscles of the posterior region of the leg. It was difficult to separate 
that aponeurosis from the muscles, and in raising it, there was discovered a yellowish lar- 
daceous tissue, that was nothing else than the muscular fibre, which had undergone trans- 
formation ; for we could see, manifestly, the healthy fibres continue themselves with fibres 
still distinct, by their direction, to the middle of the lardacious tissue that occupied a part 
of the muscles, and which equalled, in its volume, a pigeon's egg. 

The tibia was sawn on a level with the muscular alteration : the bony tissue had not un- 
dergone any sensible modification, except that the osseous cylinder was a little thicker, the 
medullary canal was a little dilated, and the marrow which it contained had undergone an 



EXPLANATION OF PLATE I.— FRONTISPIECE. 171 

alteration similar to that of the muscles, opposite the point where I he tumor existed ; it was 
firm, and resembled the degeneration of the muscles already described, differing from it 
only by the absence offibrous texture. 

The exostosis of the opposite side presented a thickening of the periosteum, which dimin- 
ished from the centre to the circumference of the exostosis ; it was very adherent, dissection 
separated it with difficulty, and where it was raised, we distinguished on the osseous tissue 
of the anterior face of the tibia, a slightly projecting circle, of which the circumference was 
formed by small osseous tubercles that produced on the bone a little relief. In this respect 
it was like the syphilitic circles that appeared on the skin, the centre of which was formed 
by sound integument. The bone being sawn in this place presented a hypertrophy of its 
tissue. Its cellules were more developed, the medullary canal seemed a little dilated, the 
marrow had undergone that hardened yellowish transformation described above. 

The lateral glandular masses of the neck were composed of glands joined together, but 
still distinct, each having nearly the volume of a walnut. 

The interior of the glands presented no alteration ; they were a grayish white tissue, of 
an uniform aspect ; there was merely a simple hypertrophy. 

The greater part of the mesenteric glands were hypertrophied like those of the neck ; they 
were not so pale : no ulceration was found in the intestines. 

The lungs presented, in their lateral and posterior surface, spots of a violet hue, which 
were indurated kernels, that, at first view, resembled those little masses seen in pneu- 
monia, when patients have died. We found no pus in any of these kernels, which, divided, 
presented a deep red tissue, and friable. In the left lung, there were five small cavities, 
half filled, and containing a whitish viscous, and a grayish pultaceous matter, which seemed 
to have issued from the walls of the ulcers, that were soft and gray. The largest of these 
cavities could contain a small nut. They were situated near to each other, in the inferior 
part, and near the external side of the lung. 

There was uncertainty as to the nature of the pulmonary alterations, and it was difficult 
to say if they were syphilitic — if those centres contained tertiary syphilitic tubercles, that 
had been softened and expelled, or if they were the result of a purulent absorption. 

The other organs presented no alteration. 



EXPLANATION OF PLATE I. 



On the face may be seen a disseminated tuberculous eruption ; on the right side of the 
forehead is a tubercle surrounded by an areola and a circle of papulae, in the form of an iris. 

Ou the left side of the forehead some tubercles have desquamated, and are surrounded 
by an epidermic border. 

At the inferior part of the iris of the left eye is a tumor analogous to the tubercles of the 
skin. 



CHAPTER XI. 

TERTIARY SYPHILIS. — GENERAL SYMPTOMS. 

They' are liable to be confounded with other affections. — This form loses in a great measure its specific 
character. — The secondary nearly always has preceded the tertiary disease. — Lupus Syphiliticus : 
General treatment — Local treatment. — Pains in the hones: treatment. — Inflammation of the Peri- 
osteum. — Bones diseased : treatment. — A prevailing error that the disease of the bones is caused by 
mercury. — Osseous Tumors: treatment — Iodide of Potassium. — Dead pieces of bone should be 
removed. — Blisters. — Deep seated Tubercles of the cellular tissue : treatment. 

The specific virulence of syphilis appears to diminish in proportion as it is diffused 
through the system, and according to the depth of the tissues involved — thus we have 
first chancre, inoculating wherever a particle comes in contact with the living tissues 
not protected from its action ; next the secondary symptoms, more diffused and 
spreading over the whole surface, but still in certain ways communicable ; and, 
lastly, we have what are now generally distinguished as the tertiary symptoms, when 
the disease loses so much of its specific character as in many cases to be scarcely 
distinguishable, and it is probable that it is finally extinguished by an insensible gra- 
dation. This is especially the case when syphilis in its tertiary stage is communi- 
cated by hereditary transmission ; and its communication in any other way may be 
a matter of some doubt ; though I should hesitate to deny the possibility of direct 
absoiption. In being transmitted from parent to child, the disease undergoes a 
still further modification ; and, losing its specific character, it developes itself in 
some one of the varieties of scrofula. 

From the nature of the tertiary symptoms, and the ease with which they may be 
confounded with other diseases, the diagnosis is involved in much obscurity. We 

172 



TERTIARY SYPHILIS.— GENERAL TREATMENT, I 73 

must be guided chiefly by previous symptoms ami attending circumstances. After 
the primary symptoms the tertiary are seldom if ever developed, without the pre- 
vious appearance of the secondary, which form a characteristic drain between them. 
P>ut as tin> secondary may appear, without the primary being noticed, so it seems to 
me quite possible, thai the virus in the system may be in so small a quantity, or 
rather may find circumstances so unfavorable to its development, as to render the 
tertiary form its first sensible manifestation. 

With the loss of specific character in the virus, the specific action of mercury 
seems to decrease, and probably in the same proportion. And in this point, I am 
forced to disagree with the school of Iiicord. This truly eminent surgeon thinks 
that the specific action is more strongly shown in the secondary than in the primary 
stage. On the contrary, I think that the whole difficulty in the primary stage is 
in bringing the antidote in contact With the poison ; and I shall never hesitate to 
meet the virus at its first onset, when mercury can be administered with any proper 
regard to peculiarities of condition. 

The more tertian/ symptoms resemble those termed secondary — and it may be 
difficult to draw the line where the one finds and the other commences — the more 
does the treatment conform to that of the secondary affections, and the more benefit 
is derived from the mercurial preparations. 

Among the first of the symptoms which may be classed as tertiary, are lupus 
syphiliticus, or deep-seated tubercles of the skin and mucous membrane. These 
most frequently appear on the alse and lobulus of the nose, but sometimes attack 
the tongue, cervix uteri, or the glands, where they may be mistaken for the super- 
ficial mucous tubercles. On the tongue, they have a scirrhous or carcinomatous 
character. 

Scarcely distinguishable from, and apparently often complicated with scrofula or 
herpetic affections, these tubercles, are slow and painless in their progress. They 
penetrate deeply, produce great deformity, and become more and more indurated. 
After a time, a softening takes place, followed by an ulceration, difficult to arrest, 
and which destroys all the tissues involved in the induration. 

This result is not uniform, as these tubercles, which may appear alone or in num- 
bers, are capable of a spontaneous resolution, or withering without ulceration, leaving 
a horny crust, which, falling off, leaves a correspondent indentation. 

As these deep-seated tubercular diseases have a general character, and require a 
similar treatment, any subdivision into species seems to me perfectly useless. 



174 TERTIARY SYPHILIS. — GENERAL TREATMENT. 

The first indication, is to attack and overcome any existing complications, scro- 
fulous, cutaneous, &c. We then resort to mercurials. Mercury in combination 
with conium, appears to have a peculiar efficacy in these cases. 

The local treatment is important. If there is much inflammation, leeches may 
be applied at a short distance from the tubercles. Irritations must be subdued by 
emollients and narcotics, opiated cataplasms and fomentations. If, on the other 
hand, the tubercles are of an indolent character, they may be treated with dressings 
of honey and proto-iodide of mercury, which, however, must not be continued long 
enough to cause irritation. Should this treatment fail, we must resort to cauteriza- 
tions with the acid nitrate of mercury, but not deep enough to produce inflammation, 
which should, if possible, be avoided, or subdued as soon as possible when it occurs. 

Washing with the chloride of soda, and afterwards sprinkling with calomel, often 
succeeds, even in the ulcerative stage, when there is not too much irritation. The 
treatment of these cases must be antiphlogistic, and depends so much upon the 
complications, that general directions other than these, can be of but little practical 
use. 

These tubercles are not confined to the*external parts, but may be developed in 
any of the internal soft tissues of the body ; and, therefore, quite beyond the reach 
of observation or of local treatment. They have certainly been found in the heart 
and brain. 

Pains of the bones are among the symptoms of this stage of syphilis. Generally, 
but not always, such pains are the first signs of inflammation, and thickening of the 
periosteum and medullary substance. They are liable to be confounded with rheu- 
matism, and are to be distinguished from it by previous symptoms, and by their 
permanent locality and circumscribed limits. The intensity of the pains may 
depend upon the difficulty with which the periosteum and medullary membrane dis- 
tend. The peculiar seve rity of these pains at night, often, but not always observed, 
has never been satisfactorily accounted for. 

Ricord holds that when these pains are purely syphilitic in their origin, nothing 
so certainly relieves them as the proper administration of mercury ; but the medi- 
cine now chiefly relied upon, in the whole management of tertiary symptoms, with 
their complications, is the iodide of potassium. 

Antiphlogistics and sedatives may suspend or remove tertiary pains. We may 
make local applications of leeches, emollients and narcotics. If these means fail, 



TERTIARY SYPHILIS.— GENERAL TREATMENT L75 

we must resort to blisters applied directly to the scat of the distress, dressed, when 
drawn, with opiated cerate, and covered with warm poultices, frequently renewed. 
This whole process ia to be repeated if necessary, and as often as necessary. Or 
if the pain return too quickly, perpetual blisters may be employed ; and only they 
who have experienced it, can describe the relief given by such counter-irritation. 
This treatment cures a great proportion of cases, but there arc some in which noth- 
ing but a deep incision, and a consequent relief of the tension ia of any service. In 
these rare cases, the surgeon must cut boldly, and the relief will instantaneously 
follow. 

The superficial bones, — tibia, clavicle, ulna, radius, scapula, sternum, and cra- 
nium, — are liable to be affected with a loosening of the periosteum, and effusion 
under it, generally caused by a superficial osteitis, forming small tumors, generally 
painful, and fluctuating to the touch. Sometimes they are indolent for a long 
period ; they may undergo spontaneous resolution, or suppurate and form abscesses. 
When laid open the bones are found to be denuded, carious or necrotic to a greater 
or less depth, or, under the most favorable aspects, presenting healthy granulations. 
A simple resolvent treatment may be tried, and a wash of the diluted tincture of 
iodine, gradually increased in strength, may be used if not contra-indicated by in- 
flammation. Blisters, and the solution of corrosive sublimate, as prescribed for 
buboes, may produce a prompt resolution. Should the progress of resolution stop 
after its commencement, it may be hastened by an application of a mercurial 
plaster, or one of conium with iodide of lead, combined wtth methodical compres- 
sion. Mechanical means might often be resorted to, I believe, in nearly every 
description of indolent tumor, with good effect. 

Should suppuration take place, we must lose no time in making a free incision 
corresponding with the axis of the bone ; and treat as in simple abscesses and affec- 
tions of the bone. 

The popular belief is that the diseases of the bones are caused, not by syphilis, 
but by the mercury employed in its treatment. We may as well put this matter at 
rest ; for whatever effects mercury may produce, it is certain that syphilitic patients 
who have never taken a grain of it, are none the less liable to a syphilitic osteitis. 
Indeed, there is no reason to suppose that mercury alone ever produces it, except as 
it has sometimes been produced in the alveola, by the ulcerations of a violent sali- 
vation. 



176 TERTIARY SYPHILIS. — GENERAL TREATMENT. 

Since, then, with this exception, mercury, without syphilis, never produces osteitis, 
and syphilis does produce it, without mercury, we must attribute it fairly to the dis- 
ease, rather than the remedy, or the disease and medicine united. 

The bones nearest the surface are the ones usually attacked ; and the disease at- 
tacks the superfices, either in circumscribed or diffused localities. Its progress is 
slow and chronic, or sub-acute. At first, its only indication may be the osteocopic 
pains before mentioned, but the swelling betrays the disease. When the tumor is 
caused by an effusion of osseus matter, the form is rough and irregular, as in the 
formation of callus in fractures ; or the swelling may depend upon an increase of 
the whole thickness of the bone. - 

Osteitis may terminate in resolution, suppuration, caries, necrosis, and induration. 

When the swelling depends upon an effusion of coagulable lymph, or an inflamma- 
tion of the organic tissues, resolution is easy. In the spongy bones, those of the 
face particularly, suppuration is most frequent. Necrosis arises when the inflamma- 
tion is very violent, from a sudden effusion in the bony tissues, or the destruction of 
the nutritive vessels around them. The permanent induration depends upon an 
effusion of the inorganic matter of the bones. 

Until the osseous tumor is developed, the treatment must be the same as for the 
osteocopic pains and periostitis. Afterwards, blisters, followed by mercurial oint- 
ment, from half a drachm to a drachm a day, on the denuded surface, combined with 
the internal use of mercury, when not contra-indicated, sudorifics, and vapor baths, 
will produce the happiest results. The iodide of potassium may be given in prefer- 
ence to mercury, and in scrofulous complications, the iodide of iron. This treat- 
ment should be continued while any pain remains, or if the swelling increases or di- 
minishes, but when the tumor becomes decidedly indolent and permanent, we may 
as well stop, and avoid exhausting the system uselessly. 

In suppuration, or caries of the bones, and especially bones of the face, we must 
either dispense with the use of mercury, or watch it with the greatest care. In these 
cases the combinations of iodine and potassium have almost entirely superseded 
mercurials, and the cures effected by these preparations are almost miraculous. Pa- 
tients have been restored, when the bones of the face, and even the skull, have been 
very far advanced in the progress of destruction. 

There is one important indication in regard to syphilitic caries, particularly of the 
face, which must on no account be neglected. As soon and as fast as the diseased 



ti:i;i'i\ky syphilis.— <,i:\i:i; \i. tklatm i:\t. 177 

portions <>t' bone are separated from the Bound they must he removed. Caries au- 
gend era caries, like the rotting of a tree, or the progress of gangrene. Pieces of 
dead bone, tike other foreign substances, require i<> be removed before suppuration 
can cease. The neglect of making such removals may cause the most serious conr 
sequences, or even death itself, from the .suppuration being kept up, ami the dis- 
d surface extended until u invades the bones of the neck, the skull, and per- 
haps the brain itself; hut even in the worst cases, the recuperative powers of the 

human system are truly wonderful. Colles mentions an instance in which a patient 
coughed up a portion of the ring of the firsl vertebra, with one half of the articula- 
ting process on one side, and one third on the other. Still he recovered, married, 
and lived for several years afterwards ! 

The hones of the nose, \\ heu suppurating, must be frequently examined, and at 
tin- proper time the loosened parts removed by the forceps. The same should be 
done in regard to the palate; and in extensive ulcerations of the upper-jaw, and 
where the hones are too large to be removed through the nostrils, the skilful sur- 
geon will find some means of breaking them down. The instruments employed in 
lithotrity have been successfully used for that purpose. 

Among the best medicinal applications in these cases, is the use of blisters, con- 
tinuallv applied as near the diseased part as possible. 

When exostosis has occurred, it does not require to be meddled with, unless it 
produces too great a deformity, or interferes with the performance of important 
functions. 

Late among the tertiary symptoms of syphilis, and in greatly undermined consti- 
tutes, the affections denominated deep-seated tubercles of the cellular tissues are 
developed. These tubercles are sometimes isolated, but generally pretty numerous ; 
and they may appear on any part of the body, either separated or in groups. The 
substance of the tongue is not unfrequently attacked by them. 

They begin with a scarcely perceptible, hard tumor, united to the skin, but move- 
able on the neighboring parts. They grow slowly and without pain, for five or six 
months or more, when they attain the size of a nut, become very hard, and adhere 
at all points of their surface. The next appearance is of an obscure fluctuation, 
which gradually becomes more distinct, and the skin changes to a red or purplish 
color, grows thin, and finally is perforated at several points, from which an ichorous 
pus is discharged, carrying with it organic remains. Extensive irregular ulcerations 



178 TERTIARY SYPHILIS. — GENERAL TREATMENT. 

succeed, that continue until the shell of the tubercle is entirely thrown out, when the 
reparative stage commences, and a cicatrice is formed, resembling that of one suc- 
ceeding a burn. These tumors will arise on different parts of the body in succes- 
sion, and go on for a series of years, in spite of all the remedies we can use. Here 
again we can derive no benefit from mercurials, since these symptoms appear, gener- 
ally, in patients on whom mercury does not exert its specific action. 

The abortive treatment of such tumors, when they appear in situations where it 
can be practised, is very clearly indicated. M. Cullerier advises that they should 
be attacked with blisters and caustics. This plan may answer ; but the more safe 
and simple method seems to me to be extirpation. The knife I conceive to be an 
improvement upon the caustic, something as chopping down a tree with an axe 
is on burning it off at the stump. At any time before the suppurative stage, if not 
too numerous and too much agglomerated, they may easily be cut out, and the 
wound united by the first intention. 

When suppuration takes place, as in other cases, we must allay inflammation by 
emollients and local sedatives ; mercury can only be used with advantage when the 
suppuration leaves indurated venereal ulcers, which must be treated as in other simi- 
lar conditions, in earlier stages of the disease. 

The general treatment is that adapted to scrofula. Bitters and tonics may be 
given ; and iodine alone, or combined with iron, may be useful in promoting resolu- 
tion, when extirpation cannot be performed, from the number or the situation of the 
tubercles. 

It would be impossible, without being unprofitably tedious, to go fully into all the 
obscure symptoms and complicated diseases, which may be referred to syphml in 
its last stages. Our guide to the diagnosis in these cases, must be to a great ex- 
tent the previous history of the patient. And as these symptoms gradually lose their 
specific character, we are to be governed the more by general principles of treatment. 



/ 

/ 



* 



CHAPTER XII. 



SYPHILIS IN INFANTS. 



Disease inherited from a parent, contracted from a nurse, or by other infection from a person having 
secondary syphilis. — Curious case in illustration. — At the time of birth the child manifesting symptoms 
of the disease. — Sometimes the symptoms are not seen until several days or weeks afterwards. — The 
ordinary symptoms are copper colored spots on the skin ; ulcers in the throat. — Consequences if 
imperfectly cured. — The disease in the infant highly contagious. — Treatment : mercurials. 



There is no class of venereal diseases more curious and important than syphilis 
infantum, and none which more forcibly shows to us the necessity of police regula- 
tions, for the prevention and eradication of affections of this specific nature. 

In regard to such measures we need answer but the two following questions : 

Firstly. Is the eradication of syphilis desirable? 

Secondly. Is it possible \ 

Both questions are answerable in the affirmative. If any moral argument were 
needed, it is most especially to be found in that phase of syphilis we are about to 
present. 

Infants are, of course, subject to a primaiy infection, by inoculation from chancre 
on the mother at the period of birth, or in any other way, the same as is the adult. 
It is not this form of the disease to which I would now invite attention. 

Syphils infantum, is that kind or development of the disease by which the foetus 
is affected, from a constitutional taint, inherited from the father by impregnation, or 
from the mother in generation or during utero-gestation, or which it may receive 

179 



SYPHILIS IN INFANTS. 180 

from its nurse, or by other communication of secondary syphilis, to which infancy 
seems to be peculiarly liable. 

I have found this disease developed under the following circumstances. 

A man, who had had syphilis, but who supposed himself to be cured, marries : 
his wife in due time becomes pregnant, but before the seventh month, or at any 
period after the third, miscarries : a second or third miscarriage, begets suspicion of 
the cause, and upon examination, the foetus is found to present evidences of dis- 
ease. The cuticle is loose, and readily peels off in patches, the nails are wanting, 
and the face is shrivelled. Neither of the parents may exhibit appearances of syphi- 
litic contamination but if they are put under a mercurial treatment, the next child 
may be born in full time, and perfectly healthy. 

But in some cases, those perhaps where the venereal taint is less, or the vital 
powers greater, the child is born at full time, but in such a weekly state that it lives 
but a few hours, copper colored eruptions are seen about the anus and genitals, and 
sometimes spread over the whole body, and the countenance has the semblance of 
extreme old age. 

But in other cases, where the disease is of still less virulence, the child, when 
born, is apparently healthy, and so remains for a period of from eight days to as 
many weeks. Then copper colored spots break out around the anus, upon the 
genital organs, and the inside of the thighs. The child's voice is a kind of hoarse 
screeching, showing an attack upon the throat, and ulcers are formed at the angles 
of the mouth, while apthous ulcerations spread over the mucous membranes. A 
discharge flows from the nostrils ; ulcers and fissures spread upon the skin ; the 
glands enlarge, without much inflammation ; the child emaciates ; the skin becomes 
flabby, and it dies, greatly attenuated and exhausted. 

This is the course of the disease when it is not arrested by treatment. Its viru- 
lence is certainly modified in some respects, for we do not -find those deep and 
frightful ulcerations of the face, which affect the adult, nor does the disease often 
go on to the tertiary affections of the deep-seated tissues, except when imperfectly 
cured, when it may be followed by spinal curvature, disease of the hip-joint, and 
other deplorable results. 

The child may receive the syphilitic taint from its nurse in sucking at the breast. 
Mr. Colles thinks that it does not become infected by the nurse unless the nipple is 
ulcerated ; but I am disposed to look upon this ulceration as an effect or accom- 



SYPHILIS IN IN KAN I 1*1 

panimonl rather than a necessary condition of the infection, ^till the communica 
tion of the disease appears to l>. % generally carried on by ih<' macous surfaces. 

Hut ii" the infant may be born with the disease, or receive it after its birth, !>y 
absorption from the mother, from a wet-nurse, or even from a dry-nurse, when 
strongly exposed to what I have termed the secondary affection, the malady so de- 
veloped in the infant possesses a singular power of contagion. Though the disease, 

thus derived, has a very mild character. 

For example : A syphilitic infant will aflect its nurse. Ulceration, appearing 
around the nipple, is followed by ulcerations of a peculiar description about the 
na, and from those the disease 1 , evidently of a secondary type, can be communi- 
cated to the husband. More than this — whole families of children have been known 
to he infected, from one to the other, the virulence of the disorder decreasing with 
each step from its source. 

One fact in this connexion is worthy of notice. Though the syphilitic infant 
readily poisons the hired nurse, its own mother does not seem to be subject to this 
infection ; and the only reason that, can be given for this is, that she is already 
thus affected, and is not liable to a fresh infection in the secondary stage of the 
disease ; though, like every other person, perfectly liable to the primary disease. 

In the treatment of syphilis infantum, we are to be governed by the general 
principles of the treatment of this disease. If the infection come from the mother, 
she should immediately be treated with mercurials. If from the father, both must 
be put under treatment. If the child has a hired-nurse, she also must be put under 
the mercurial influence. 

In many cases the administration of mercury to the mother or nurse, answers 
for the child ; but this is not always the case, and then we may give it directly, by 
baths, inunction, or internally, but in either case in doses mild in proportion to the 
tenderness and susceptibility of the infantile state ; otherwise we may produce con- 
vulsions, and suddenly destroy the life we are endeavoring to save. Children are 
not subject to ptyalism, nor the mercurial fever, which sometimes attend its exhibi- 
tion in adults. The mildest form of the mercurial preparations is the hydragyrum 
cum creta, and therefore this is the most suitable for infants ; it may be given in 
doses of two to four grains, twice a day. 

The local treatment required, is to be guided by the same rules, modifying the 
applications to the age and strength of the patient. 



182 SYPHILIS IN INFANTS. 

Syphilis infantum, then, though certainly an effect of the specific virus of syphilis, 
exhibits the following curious modifications. It is infinitely more contagious — those 
who are exposed to the infection, rarely, if ever, escaping. The symptoms are always 
much the same, and not like the other forms of the disease, modified or varied by 
differences of age, temperament, or other circumstances. In the third remove, the 
affection is entirely a local one and has a mild character, becoming less and less 
virulent, the farther it is distant from its source, till it degenerates into diseases, not 
requiring a specific remedy for their cure. 

I need not say that this is a disease to which the family physician should direct 
his serious attention ; nor that the entire confidence of the parties is of the greatest 
importance. Should there be a reasonable ground of suspicion, or, rather, should 
there be a strong probability that the father had secondary syphilis at the period of 
conception, I should not hesitate to prescribe a mild and carefully regulated mercu- 
rial course during utero-gestation : but each physician must judge for himself of the 
particular conditions that either warrant or forbid a resort to such treatment. 

Another inference will be likely to be drawn from this subject. It is that persons, 
having in them a taint of the syphilitic virus, are not in a proper constitutional state 
for entering upon the duties of matrimony. 

The dangers to infants from unhealthy nurses, and vice versa, must suggest them- 
selves to every one who reflects ; and in such a case it would be extremely cruel to 
subject a healthy nurse to the infection of a diseased child. 

The fact that an unquestionably syphilitic disease, may be communicated in so 
many ways, and through such various channels, may be important in accounting for 
its appearance, where, otherwise, it would involve a question of a very delicate and 
perplexing character. 



VENEREAL ERUPTIONS. 



The following plates exhibit nearly all the varieties of the affections of the skin that man- 
ifest the constitutional action of syphilis. It is astonishing that a single disease, at first 
strictly local, should, when the system becomes contaminated, display itself on the cutane- 
rarface in so many different forms. 

It ought always to be remembered, when diseases of this nature are presented for treat- 
ment, that all are not strictly syphilitic, which, to an inexperienced eye, appear tobe so. The 
affection may, indeed, be the consequence of impure sexual intercourse, but, nevertheless, 
it may not possess the true characteristics of the chancrous disease. It is not an uncom- 
mon circumstance for sores to occur -upon the genital organs after coition, followed by 
buboes in the groins, and succeeded, finally, by secondary symptoms in the throat and on 
the skin, which, although they are properly venereal, and are not truly syphilitic. Diseases 
of this nature were, I believe, first fully described by Mr. Abernethy, and denominated by 
him as Pseudo- Syphilis. It is not easy, in every case, to determine, whether the patient is 
affected with this or the real syphilitic affection. The history of the case is of some assist- 
ance in resolving doubts; the appearance of the original sore, when it can be seen, will 
usually afford much aid, and inoculation must, of course, be nearly always decisive in 
diagnosis. 

Several of the cases that follow, were of this kind. The eruptions had no specific char- 
acter, and they disappeared under simple treatment, without requiring specific remedies. 

183 



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EXANTHEMATA. 



PLATE XV. 

EXANTHEMA ROSEOLUM. 

This is a diffused efflorescence, or rash, preceded by slight fever and pains in the limbs, 
situated beneath the cuticle ; it is formed by increased determination of blood to the vessels 
of the skin. Sometimes there is slight extravasation, which, presenting its color through 
the transparent cuticle, gives a beautiful rose or pink hue, the intensity of which varies in 
different individuals, from the slightest perceptible tint to the deepest roseate color. 

In the forms which this eruption assumes, there is no regularity; the patches are separa- 
ted from each other by healthy skin. In rubeola and scarlatina, the papillae are raised ; in 
this variety such is not the fact ; and the eruption generally first shows itself on the abdo- 
men. Most usually it is the first sign of general disturbance from the venereal poison, and 
precedes or accompanies other eruptions. 



PLATE XVI. 

EXANTHEMA PUNICEUM. 

This is a crimson or purplish colored venereal eruption, more intense in its color than the 
roseola, and it appears in very numerous spots. As may be seen in the plate, it varies in 
its shade and form. 

The puniceous eruption makes its onset with slight febrile symptoms, and is oiten accom- 
panied with a sore-throat. Like roseola, it is frequently a forerunner of other eruptions, or 
associated with them. It is a prevalent form of secondary symptoms. In strongly marked 
cases, there is a very apparent elevation of the diseased surface, particularly in the centre 
of each patch. When it has declined, there still remains a feeling to the touch, as if there 
was a thickening of the skin ; while spili coccinea, an affection for which it may be mistaken, 
leaves a pit or loss of substance. 

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PLATE XVII. 

PUNIC EOUS PATCHES WITH PAPULJE. 

An urethritis and a vesicle on the glans was followed by lichenous puniceous patches, the 
hitler of which became set with enlarged papulae on the skin, and with minute papulae and 
:les on the scrotum. The case was cured with mercurials, sarsaparilla and warm 
ba i I 



PAPTJLJI. 



A papula or pimple, is a very small and acuminated elevation of the cuticle, with an in- 
flamed base, very seldom containing a fluid, or suppurating, and commonly terminating in 
scurf. Papulae terminate by resolution, generally with furfuraceous desquamation of the 
epidermis. Willan divides this order into Strophulus, Lichen and Prurigo. 



PLATE XVIII. 

PAPULiE ELONGATE. 

This is a variety of Papulae described by Judd, and shewn on Plate XVIII. It is thus 
characterised : It appears to be merely the natural rough asperities, or papillae, as they have 
been termed, of the cuticle, enlarged arid distended in wheals during the excitement caused 
by one kind of venereal virus ; attended by partial fullness, from turgescence of the cuticle, 
and inflammation of the parts immediately beneath it ; forming a sort of red cutis anserine. 
This eruption is accompanied by sore throat, and terminates in furfuration ; it is a very 
scarce form of cutaneous affection. 

187 



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PLATE XIX. 

LICHEN VENEREUS. 



Tins tfl a pimple which may, through accidental circumstances, be made to vesicate, 
suppurate, and ulcerate. Syphilitic lichen differs from common lichen in having a large 
number of papula; containing lymph, and which oftener become vesicular, or even pustular, 
wherever they are subject to a little friction from the clothing, and especially upon parts 
covered by hair. It is more apt to scab and incrust than common lichen. 

In four or five months, a second set of lichen, not unusually follows the first ; and if it is 
of the solitary form, it almost always is of a larger character than the primary eruption — 
fewer in number, disposed to be vesicular, often contains opaque lymph, forms incrustations, 
and frequently is blended with favi. It often happens that lichen solitarius is followed by 
lichen circumscriptus, or lichen racemosus. 



PLATE XX. 



A CHANCRE AND BUBO, FOLLOWED BY LICHEN CIRCUMSCRIPTUS, VES- 
ICLES, MACULE, AND ULTIMATELY LICHEN SOLITARIUS. 

The large patch represented in the plate, was situated on the side of the chest. The 
upper circle of vesicles, copied from near the angle of the mouth, is a perfect picture of 
Herpes circinatus. The red spot, drawn from one on the cheek, is similar to macuke cruen- 
tatae. It will also be observed, that there are a few spots representing lichen solitarius, 
which came out on the body and arms. This eruption appeared the first of March, on a 
patient who was infected with syphilis about the last of the previous December. 

189 



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PLATE XXI. 

LARGE VESICULAR LICHEN. 

The patient from whom this drawing was taken, had an eruption of large vesicular lichen, 
elevated more than a line above the surface, set upon a vascular base. On his back they 
wore the largest, and disposed in rows, containing about three each. Others, less prominent, 
were arranged in the form of a crescent. The larger ones, chancing to be on the skin 
covering superficial bones, suppurated. In the folds of the prepuce are marks of three recent 
sores, and the remains of a fourth with much hardening. The inguinal glands are enlarged. 
On the lower left hand corner of the plate, may be noticed the eruption in the progress of 
cure, each spot reduced to about the size of a pin's head. 



VESICUL^. 

This order is placed after papulae, as it often happens that lichen may be a vesicular dis- 
ease. Vesicles are often the sequel of lichen. They contain a clear watery serum, which 
has had the effect to elevate portions of the cuticle. The general character of all vesicular 
eruptions is such as I have described; but as the disease advances in its progress, the en- 
closed lymph of the vesicles acquires a considerable degree of opacity, and might almost be 
deemed purulent. The eruptions appear to consist of Herpes solitarius, H. confertus, H. cir- 
cinatus, and Rupia. 



PLATE XXIL 

HERPES VENEREUS. 

In this plate may be seen three varieties of Herpes — the isolated vesicles form what is- 
called solitarius ; those in patches, form the variety of confertus ; and those disposed to 
take the annular arrangement, are the circinatus variety. 

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PLATE XXIII. 

HERPES CIRCINATUS. 

AjfTBB sexual intercourse, the subject of this plate had, on the penis, a little circle of ves- 
icles, such as appeal - on the upper row of the plate. The dark colored spot was the first 
herpetic centre, and is seen as it looked covered with a scab. This degenerated into a 
small ulcer at the end of a few days. The other rings soon disappeared by concreting and 
drying off. The ulcer healed readily. Ten weeks from the period of infection, he com- 
plained of a sore throat, which was covered with a diffused rose-colored redness. Shortly 
after a mottled redness came out on the skin from head to foot, accompanied with feverish- 
ness. The eruption afterwards put on the character of the puniceous patch, and ultimately 
a concentric eruption of small vesicles, as seen in the lower'part of the Plate. The glands 
at the back of the tongue enlarged, and there were superficial circular ulcerations in the 
throat and fauces. He had stiffness in the right leg, and pains in the left ancle. Six 
months elapsed before this patient completely recovered. He was treated entirely without 
any of the merer -ial preparations. 



PLATE XIV. 

RUPIA PROMINENS. 



The subject from whom this drawing was designed, was a strong and healthy man. 
Some days after connexion with a woman of the town, vesicles made their appearance on 
the dorsum of the penis, which gradually extended and became a foul sore. The glands of 
the groin suppurated. About six weeks after contamination, he was attacked with super- 
ficial ulceration of the left tonsil, swelling of the uvula, and sloughing of the posterior nares. 
The tonsils soon after ulcerated deeply, and threw off ash-colored sloughs. His body and 
limbs at the same time were covered with straw-colored vesicles, very similar to the 

193 



194 EXPLANATION OF PLATE XIV. 

primary sore. [See Figures 1, 2, 3, of the Plate.'] A few days afterwards, his legs and 
thighs presented many dark conical scabs, as large as dimes. [See figure 5.] When one 
of these crusts fell off, it exposed a large foul ulcer, the size of a half-dollar, which began to 
granulate from the centre. [See figure 6.] Some of the smaller scabs, left, when they fell, 
a sound base, marked by a deep rose-colored stain. [See figure 7]. 

Three months after contamination, the rupia had nearly gone, when an eruption of tuber- 
cles appeared on his face and forehead. 

Five months from the onset of the primary disease, the patient had quite recovered — 
having, in the time, had a second eruption of tubercles and pleuritis. 

This patient was cured without the use of mercury. 






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PLATE XXIV. 

ECTHYMA VENEREUM. 

The general description of Ecthyma is thus rendered by Willan : " An eruption of the 
inflamed pustules, termed phlyzacia, usually distinct, and arising at a distance from each 
other. It is commonly indicative of some state of distress under which the constitution 
labors, and though it is not attended with actual fever, yet a degree of general irritation or 
erethism is often present with it." The venereal form of it, appears to be accompanied 
with more constitutional disturbance and fever than the common form. The inflammatory 
action runs high. About the same time that pus is secreted in the centre of the pustule, 
the cuticle is gradually separated as the distention increases, and is raised into a conical 
shape. In persons with a languid circulation, very large portions of the skin are frequently 
seen of deep crimson or chocolate brown color; and when the first eruption of ecthyma is 
gone, it is not unusual to see almost the entire skin of the leg and shin covered with these 
frightful dusky red stains, marked by numerous dots, depressions, and loss of substance, the 
ivation being filled by sloughy cellular membrane. [See the Plate, shotving the most 
ordinary appearance displayed hi/ this affection]. 



PLATE XXV. 

ECTHYMA VENEREUM : CLUSTERED LICHEN. 

The patient from whom this drawing was made, had a pimple on the penis near the 
pubes, three days after intercourse with a prostitute. He was also affected with urethritis. 
In a few days the sore healed, and the discharge from the urethra ceased. 

195 



196 EXPLANATION OF PLATE XXV. 

Fourteen weeks after the infection, he had ecthyma phlyzacium covering him, a capite ad 
calcem. On the arms and legs, the pustules were largest. There was hoarseness and an 
ulcer in the throat. In about a fortnight the eruption began to decline. A few large lichen 
came out here and there on the body. 

When the first ecthymatous eruption had passed away, a large part of the person was 
covered with dark red, or chocolate-colored stains, as seen in figure 1 of the plate. 

This eruption was succeeded, on the healthy portions of the skin, by a few very small 
and flat pustules of ecthyma psydracium venereum, having little or no areola. [See plate, 
figure 2]. 

Afterwards, a fresh eruption of middle sized lichen appeared, in groups. [See plate, 
figure 3]. At this time might be seen the chocolate-colored stains of the first, the straw-col- 
ored pustules of the second, and the red lichenous patches of the third eruption, all at one 
view upon the skin. 

This patient had, during the progress of the disease, nocturnal pains, and dropsical effu- 
sions. He was cured without the use of mercury, but he took the iodide of potassium. 



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PLATE XXVI. 

LARGE ECTHYMA. 

Three days after connexion, the patient who furnished the original for this plate, observ- 
ed a iedness on the prepuce. In a few days the inflamed spot became the base of a pus- 
tule, which shortly afterwards ulcerated. The glands of the groin swelled and suppurated. 
For this condition, he took mercurial pills and used a large quantity of mercurial ointment. 
His gums were kept sore for nearly three months. After this treatment, he remained well 
for two years. Without having had, in the interval, intercourse with any person except his 
wife, who was free from disease, he was attacked with an ulcer on the right tonsil, an en- 
largement of the right submaxillary gland, and an eruption of large ecthyma, which came 
out, as he states, slowly, first on the face, next the scalp, then on the legs, and afterwards 
on the body, followed by considerable disturbance of health and some fever. An extensive 
slough formed in the throat, and the pustules became so numerous that the case looked like 
small-pox. The eruption continued to come out during three weeks. [See the jplate~\. 

At the end of two months the ecthyma had cicatrized. Ten weeks afterwards, preceded 
by fever, a new eruption of crimson blotches, or spili cruentati, as large as sixpences, rather 
less circular than usual, appeared all over him, coming out gradually. [See the plute, 
figure 2.] In a few days the blotches assumed a coppery hue, and were much diminished 
in size. It is unusual for crimson spili to follow ecthyma — they commonly show them- 
selves first in the order of eruptions. 

The secondary disease was treated without mercury, and perfectly cured. 



MACULE. 



Under this head are arranged those affections of the cutaneous tissue, which are distin- 
guished by discoloration of the skin. The seat of these alterations is the rete-mucosum, and 
the papillary layer of the dermis. 

This order contains three varieties. 1. Spili Coccinei. 2. Spili Cruentati. 3. Spili 

197 



198 EXPLANATION OF PLATE XXVII. 

Cuprei. The two first, towards their termination become copper-colored, and resemble 
the last. They are of a decidedly crimson color ; their figure is oviform and constant — 
varying in size from a pin's head to that of a Windsor bean, slightly raised above the sur- 
rounding surface, and containing red lymph. The painted-like appearance of the eruption 
remains bright about a week ; it then gradually declines, each crimson macula becoming 
copper-colored and somewhat diminished in circumference. In about a fortnight the skin 
generally begins to recover its natural hue ; and a little prior to that period a slight depres- 
sion is commonly evident; while, on the contrary, puniceous patches leave a considerable 
rise. 

The spili coccinei and cruentati do not occur after syphilitic contamination near so often 
as puniceous patches. Other secondary symptoms but seldom follow this eruption. 

Spili cuprei differ very considerably from the former varieties, being of a yellow color 
from the commencement. Nor do they come out at once like those just described ; on the 
contrary they appear slowly and singly, are very long in forming, more slightly raised, and 
frequently becoming confluent, form copper-colored patches as large as the palm of the 
hand. They seem to be produced by some organic change in the rete-mucosum, and are 
very permanent, at times lasting for years, appearing to be little or not at all affected by 
the longest courses of mercury. 



PLATE XXVII. 

SPILI COCCINEI. 



The patient from whom the drawing on this plate was taken, had, the seventh day 
after intercourse, two small level sores on the penis ; he also had urethritis, which made its 
appearance on the eighth day. Under treatment, which comprised mercury, he got pretty 
well. He had afterwards a relapse ; a swelled testicle, a bubo that suppurated, with en- 
larged inguinal glands on the other side. At the end of five months from the period of in- 
fection, an eruption of crimson maculae came out over his body and limbs, mostly of a cir- 
cular form, and some as large as sixpences. [See plate.] In the course of twenty days 
the eruption had vanished without leaving any marks behind. A little mercurial ointment 
was employed in the last instance.* 

The coloring of this plate should have more of a crimson color, and it is wrong to call it, as is done at the head of the 
plate, the copper spot. 











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PLATE XXVIII. 

SPILI CRUENTATI. 

The subject furnishing this eruption, had a sore upon his penis, which he healed with 
sugar of load water. Ten weeks afterwards he had an eruption all over his body and 
limbs, but none on his face. Each spot was of a deep crimson color, of an oviform shape, 
from the size of a pin's head to that of a pea. They were slightly raised upon the level of 
the skin, but were flat upon the surface. [See the upper part of the plate.'] It was ushered 
in with fever. In about seven days the spili assumed a copper-color. [See the lower part 
of the plate, representing their declining stage.] In two weeks more all marks had disappeared. 
This case was treated with mercury. 



PLATE XXIX. 

SPILI CUPREI. 



The patient from whom this drawing was taken, was attacked, three weeks after con- 
nexion, with enlargement of the glinds in both groins, which went on to suppuration. Eight 
weeks later a small sore on the penis began to make its appearance, and looked merely as if 
the patient had rubbed the skin off*. For a long time it resisted every attempt at cure, and, 
after healing several times, broke out again. When it finally healed over, much induration 
was left. He took mercury and his mouth was kept sore for four weeks. 

During the time his mouth was affected by mercury, a slight crop of ecthyma appeared 
on his shoulders and back. This eruption was removed, but from irregularity in living, his 
groins again suppurated. He neglected all treatment. 

Fifteen months after the primary attack, he returned for medical advice, with five or six 
sinuses in the groins, discharging thin unhealthy pus. The lacuna where the abrasion on 
the penis had been seated, was red and pouting. His general health seemed good. 
Shortly after, copper-colored stains showed themselves on the skin of the lower part of his 
neck, breast and shoulders. They came out, few at a time, in various forms ; some as 
single spots, others coalesced in groups. [Sec the plate.] The induration was still unab- 
sorbed. He was treated again with mercury : the groins healed and the disease was at 
length arrested ; but two years afterwards, although in good health, the spili cuprei remain- 
ed visible. 

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The chief characteristics of the syphilitic varieties of Tubercles, are, that they consist of 
considerably raised and inflamed masses, of a crimson color — that they are permanent 
during weeks or months — at times suppurate, though very slowly, or they subside gradu- 
ally. Two varieties are presented : — 1. Phymatosis ovata. 2. Phymatosis annulata. 



PLATE XXX. 

PHYMATOSIS OVATA. 

A patient had sexual intercourse with a woman of the town, and, ten days afterwards, 
observed a small spot, not larger than the head of a pin, on the inside of the prepuce, look- 
ing as if the cuticle was slightly abraded. 

A few days after, the sore had become deeper, and pus formed on it. It continued to 
grow worse, and looked sloughy for three weeks, although the patient was under the mer- 
curial remedies. Ten weeks from the time of commencing the treatment, the sore had 
cicatrized, leaving no induration. His mouth had been kept sore for four weeks. 

Two months from this time, he began to feel unwell ; he had pains in his shoulders and 
shin>. A puniceous eruption broke out all over him, accompanied by a sore throat and red- 
ness of the fauces. In twenty days more this was succeeded by an eruption of tubercles, 
which were raised slightly above the general surface, of an ovoid form ; the base of each was 
surrounded by some inflammation. He had also iritis. [The top of the plate shows the ap- 
pearand of tin tubercle^. 

In about six works the eruption had so far subsided, that it had become of a copper- 
color, or sort of yellowish-brown, as shown in the lower part of the plate, which did not 
wholly disappear for several months. 

The general treatment was with the preparations of mercury. 

201 



202 EXPLANATION OF PLATE XXXI. 

PLATE XXXI. 

PHYMATOSIS ANNULATA. 

The person from whom this drawing was taken, denied having ever had venereal, but 
her habits of life were strong evidence against her. On the first application for advice, she 
had a peculiar eruption, which had continued for many months, about the eye-brows, on the 
back of the neck close to the hair, and on the shoulders and arms. She had also sore 
throat, and had had iritis, which had yielded to mercur}'. 

Tubercles made their appearance, of this varietj 7 , which is scarce ; their color was dark 
red, considerably elevated, of a circular form, looking as if they contained a red-brown 
fluid, each patch being about the size of a half-dime, several tubercles developed on the same 
base, disposed in circles, and raised the fourth of an inch above the surface. Those seen 
in the upper left corner of the plate were situated on the back of the neck ; those marked 2, 
on the face and neck, and those marked 3, at the bend of the arm. The patient was treated 
with mercury and sarsaparilla, which did not seem, after a long trial, to be of any service. 
The tubercles at length suddenly disappeared, apparently spontaneously. 










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SQUAMiE. 

Squamous disease is especially characterized by inflammation of the dermis, and by the 
production of abnormal epidermis, in the form of thin lamina), or scales. I shall notice two 
varieties : Lepra and Psoriasis. 



PLATE XXXII. 

LEPRA VENEREA. 



This is an eruption which makes its appearance in different parts of the body, of raised 
and circular patches, which are soon covered by thin, semi-transparent, quadrangular 
scales of white and morbid epidermis. The patches are prominent around their circumfer- 
ence, and somewhat depressed in the centre ; they increase by the extension of their peri- 
phery, while the central area gradually returns to the natural state. [See plate.'] 



PLATE XXXIII. 

PSORIASIS VENEREA. 

The patient who furnished the subject for this plate, had a small vesicle on the glans 
penis, a few days after connexion with a woman of the town. Three days from the time of 
its appearance it broke, and the part around it had begun to indurate, and a gland in the 
groin was swollen. Mercurial frictions were used, and his mouth kept tender for a month. 
The chancre had healed at the end of two weeks, and the bubo subsided without suppuration. 

203 



204 



EXPLANATION OF PLATE XXXIII. 



Six months from the commencement of the primary disease, the skin of the head, body, 
and limbs, was covered with an eruption of psoriasis, in large oval and round patches, 
from the size of a dime to that of a half-dollar. The irritation of the scalp was so great as 
to cause suppuration of the sub-maxillary glands. The patches continued to enlarge, until 
some of them attained the size of the palm of the hand. Sulphur in different forms, was 
administered, with sulphuret of potassa, producing some improvement, but without any 
very decided benefit. The eruption now assumed the form of concentric patches, the skin 
within the circle becoming daily more healthy. [See the plate.'] The compound calomel 
pill, and the decoction of sarsaparilla was next tried, with better effect. At the end of 
three months, the eruption had disappeared, and the patient was well. 



INOCULATION. 

In the course of the remarks that I have made, in the previous portion of this work, I 
have frequently spoken of the utility of inoculation, in deciding upon the true syphilitic 
character of disease. When error is properly and carefully guarded against, it is a method 
which may be pronounced almost infallible, and its great importance, both in the treatment 
of the affection, and in settling medico-legal questions in cases which sometimes arise, 
will be apparent upon the slightest reflection. 

M. Ricord has pursued this subject with great judgment and enthusiasm, at the Venereal 
Hospital of Paris, where his opportunities have been most ample for conducting experi- 
ments. He has done science great service by the new light that he has thrown upon the 
nature of venereal affections. The following table, that I have borrowed from his work, is 
an analysis of experiments made by him, between the years 1831 and 1837. It possesses 
much interest. 



A TABLE OF THE INOCULATIONS 

i 

MADE IN THE MALE WARDS. 

SYMPTOMS WHOSE PUS PRODUCED THE CHARACTERISTIC PUSTULE. 

PRIMARY SYPHILIS. 



CASKS ' 



Chancres in the ulcerative or progressive period — 

On the penis 347 

At the anus .............. 9 

Concealed in the urethra (larve) .......... 21 

On the lips 3 

In the throat .............. 1 

On other parts .............. 8 

Primary pustules — 

On different parts consequent on coition, on the inner parts of the thigh, or from arti- 
ficial inoculation 59 

Virulent abscess, or encysted chancres — 

In various situations ............. 18 

205 



206 TABLE OF INOCULATIONS. 

Symptomatic lymphitis, or chancres in lymphatics — CASE8 . 

Inoculated on the day of their being opened, or later ...... 11 

Symptomatic bubo, or ganglionary chancres — 

Inoculated the day they were opened ......... 42 

" " following day* . 229 



IN THE FEMALE WARDS. 
PRIMARY SYPHILIS. 

Chancres in the ulcerative period — 

On the vulva . L39 

" vagina .............. 2 

" cervix uteri .... ......... 12 

Concealed ............... 6 

At the anus 28 

On the lips 4 

In the throat 2 

In different parts 6 

Primary pustules — 

On various seats consequent on coition ; on the internal surface of the thigh, or from 

artificial inoculation 27 

Virulent abscess, or encysted chancre — 

In various situations ............. 8 

Symptomatic buboes, or ganglionary chancres — 

Inoculated upon the day of their being opened ........ 21 

" the following day or later ......... 46 



(< 



IN THE MALE AND FEMALE WARDS. 

SYMPTOMS WHOSE PUS PRODUCED NOTHING. 

SYMPTOMS OF TRANSITION. 

Chancres in the period of reparation .62 

SECONDARY SYPHILIS. 

Mucous tubercles, or pustules in various parts ........ 221 

Secondary ecthyma ............. 10 

" rupia ............. 9 

Ulcers (consequent on mucous tubercles, ecthyma, rupia, or impetigo) — 

In the nasal fossae . . . . . . . . . . . .19 

On the lips % . . 14 

" palate 4 

* Of these latter, 214 had been inoculated without result on the day of the opening. 



TABLE OF INOCULATIONS. 207 

•MM 

In the throat ............ 81 

At the anus ............. 41 

TERTIARY SYPHILIS. 

Tubercles ulcerated in the whole thickness of the skin in various situations . . 21 

Tubercles in the cellular tissue or gummy tumors ulcerated, on various scats . . 11 

Periostoses having suppurated ........... 15 

Caries ............. 10 

VENEREAL AFFECTIONS, NOT DEPENDENT ON THE SYPHILITIC VIRUS. 

Primitive buboes ....... — ..... 39 

Sympathetic " 249 

Blenorrhagia in the acute stage — 

Of the glans and prepuce (balanitis) 82 

In the urethra 291 

" vulva 31 

In the vagina 82 

" uterus 27 

At the anus 36 

Ophthalmia 6 

Blenorrhagia in the chronic stage having various seats 112 

Ulcerated swelled testicle 3 

NON-CHARACTERISTIC SYMPTOMS WHICH SHOW THEMSELVES AFTER VENEREAL AFFECTIONS, 

WHETHER SIMPLE OR VIRULENT. 

Vegetations, either ulcerated or not, having various forms and 6eats .... 28 

AFFECTIONS NOT DEPENDENT ON VENEREAL DISEASES. COMPARATIVE EXPERIMENTS WITH 

NEGATIVE RESULT. 

Atonic ulcers of the legs ............ 6 

Simple ecthyma ............. 5 

Herpes ............... 4 

Scorbutic ulcers '............. 2 

Scrofulous .............. 6 

Caries ................ 4 

Simple ulcerated stomatitis ........... 9 

Ulcerated eczema intertrigo .2 

Otitis 3 

Cancer of the uterus ............. 3 

" " rectum ............ 6 

" breast 2 

3 

4 



penis 
nose 



Abscess on various parts ............ 1-5 



PLATE XXXIV. 

FIGURE 1. — EXCORIATIONS. 

The subject of this drawing had suffered many months from a greenish purulent dis- 
charge. She was a married woman, and attributed it to a disease which her husband had 
contracted about the same period. The introduction of the instrument was not attended 
with much pain. The characters of the excoriated condition of the epithelium, and the 
color of the secretion, show the analogy which it bears to balanitis in the male. 



FIGURE 2.— GRANULAR CONDITION. 



The granular appearance of the os uteri and vagina, is a very marked instance of what is 
often to be met with in the hospitals. The subject of it was a very stout female servant. 
She stated that a discharge from the vagina had appeared eight months previously, and had 
continued to increase. The introduction of the instrument was very painful. The secre- 
tion was purulent, of a green color, of the consistence of cream, and so abundant that it ran 
out of the speculum. The analogy between this disease and the granular condition of the 
conjunctiva, in chronic affections of that membrane, cannot escape the notice of the surgeon. 

208 



— : 




ad 

r 5 



■■z 




S,v— 







z 



■1 



CHAPTER XIII. 

GONORRHOEA. 

• 
Its definition. — Its synonyms. — Its antiquity. — Maybe produced by a leucorrhocal discbarge. — Un- 
til lately regarded as a variety of syphilis. — May be complicated with syphilis. — Difference in the 
liability of individuals to contract it. — The matter will retain its infectious character for a long pe- 
riod. — Cases. — Varieties of the disease. — Symptoms of the disease, in the male, in the first, sec- 
ond, and third stages. — Prognosis very difficult 

Goxorrtice v is the name most generally given to the second order of venereal 
affections, now considered by the highest authorities non-virulent. The name, 
though certainly false in its original signification of a flow of semen, is yet the one 
adopted by general usage, and is no more objectionable than a hundred others. The 
names of Blenorrhoea, and Blenorrhagia, have been adopted by recent writers, but 
there seems to be no great necessity for such a nicety of terms where the disease 
is so well known ; though perhaps less understood than it ought to be. 

We may trace the existence of this species of venereal disease, as far back into 
antiquity as our researches can extend, and there seems to be no doubt that it is an 
affection to which the human race has always been liable; having its origin, gene- 
rally, in an unhealthy secretion from the female uterus or vagina. That an un- 
doubted gonorrhoea may arise in the male from contact with a leucorrhocal discharge 
in the female, is a fact commonly recognized in the profession. Some have sup- 
posed that it may be developed spontaneously in the male subject, under certain cir- 
cumstances of hardship and exposure, but this I greatly doubt. It may be deemed 
one of the curiosities of medical science, that gonorrhoea was for a long period, by 

209 



I' 



210 GONORRHOEA. 

eminent men, considered as bnt a modification of syphilis, and treated accordingly. 
But it has, latterly, been demonstrated to be a strictly local disease, confined to the 
mucous membrane, and affecting, by irritation and sympathy alone, the surrounding 
tissues. 

It may be complicated with syphilis — both may be contracted at the same time, 
or either one during the progress of the other. Syphilis has undoubtedly often been 
mistaken for gonorrhoea, from the presence of chancre in the urethra; and in this 
case the syphilitic ulceration has produced a purulent discharge from the mucous 
membrane, which was followed by secondary symptoms. But in no instance has 
the matter of simple gonorrhoea given rise to chancre ; and in no instance have 
secondary symptoms followed such an affection. 

Gonorrhoea may be defined as an inflammation, more or less acute, of the urethra, 
or other parts of the genito-urinary passages, accompanied by the secretion of a 
muco-purulent fluid, of a yellow or greenish appearance, accompanied with pain, 
itching, or irritation in voiding the urine, and, in the male, frequent, involuntary, and 
painful erections of the penis. 

Though an inflammation and secretion answering to this description may be pro- 
duced by connexion with women who are affected with inflammation of the vagina, 
the lochial, or menstrual discharge, fluor albus, and ulcerations of various kinds, or 
by masturbation, habitual costiveness, inflammation of the prostate gland, calculi in 
the bladder or ureters, piles, excessive use of fermented liquors, exposure to cold and 
wet, external injuries to the penis, and even the irritation of teething, and intestinal 
worms in children ; yet we may doubt whether the affections thus occasioned, are 
communicated by infection with the same facility as is exhibited in the disease in its 
more common mode of appearance. 

In proportion as the discharge of gonorrhoea becomes purulent, its contagious 
character increases; but whether all such discharges, in whatever manner produced, 
are equally contagious, or whether the disease they cause is equally severe, is a mat- 
ter of some difficulty to determine. It is my opinion that the contagiousness of 
gonorrhceal matter varies in every degree, and that the violence of the symptoms 
bear some proportion to the cause of their development. 

At the same time, the difference in individuals, as to their liability to be infected, 
is very great, owing to temperament, and it would seem to custom. The same cause 
that will infect one person will produce no result upon another ; or the same person 



OONORBHCEA. BU 

may become so accustomed to o contagion thai it shall have do efieel upon him. 
The fact thai a woman docs not cause a gonorrhoea] discharge on one man, is no 

proof thai Bhe may not on another; ami the same discharge in a w an, which had 

produced no result when habitually encountered, may rause a gonorrhoea after a pe- 
riod of absence. These tacts may be found verj important. 

In most cases, however, a contact of gonorrhoea] matter with tin- mucous mem- 

•ie of the urethra in the male, or the vulva, vagina, or urethra of the female, is 
sufficient to produce a gonorrhoea; and this effect may follow whatever way the 
matter is applied, at a considerable period after it lias been secreted, and even when 
it has become dry and hard by exposure to the atmosphere. 

Thus a man, alter using a privy, found a small piece of hardened matter adhering 
to the meatus urinarius, which he brushed off; he was soon after attacked with a vio- 
lent gonorrhoea. It has been my misfortune to prove the length of time that the in- 
fectious character of gonorrhooal matter can be preserved, in a manner most annoy- 
ing to my feelings, but which I deem it my duty to record, as a warning to others. I 
had occasion to introduce the same bougie into the urethral passages of two patients 
on the same day; and though both were free from the disease at the time, they 
came to me, a few days after, each of them with a well characterized and violent 
gonorrhoea. In the first case I could scarcely credit the patient, when he assured 
me that he had not exposed himself to contagion. I was obliged to forego my sus- 
picions when the second case appeared. On an examination of the bougie, I be- 
came perfectly satisfied as to the source of infection. Several weeks before, the same 
instrument had been used in a case of acute gonorrhoea, and though it had in every 
instance after using, been carefully and thoroughly washed, I found upon a close in- 
spection, that at some previous time, in attempting to bend it, when cold, it had 
broken into a multitude of minute, but deep fissures, in which, through all its cleans- 
ing*, the matter had remained concealed, and which, undoubtedly, propagated infec- 
tion in both of these cases. 

A gentleman from the country came to me to be cured of a smarting and burn- 
ing pain in the urethra. During my treatment, I ordered him to inject the passage 
with warm milk. Unknown to me he used a syringe which he had employed five 
months previously for a clap. In the meantime he had kept the instrument care- 
fully in a paper case. The third day after making the injection he had all the symp- 
toms of violent gonorrhoea, which he did not get rid of for four months. This gen- 



212 GONORRHOEA. 

tleman was a friend, and was in my own house ; I therefore know that he was not 
outside of the door from the time he entered until he finally left for his home. I am 
perfectly certain that he could not have contracted the disease anew by connexion 
with a diseased person. It is clear that he must have been infected by the syringe 
which had not been nsed for several months. The moment he discovered it, he said 
to me that he had clapped himself with his old instrument. 

I trust that these facts may be a lesson to others, as they have been to me, never 
to risk a similar result in future. 

Ricord has made .the following division of the modifications and varieties of this 
disease. 

First Species. Gonorrhoea in the female : seated in the vulva, the vagina, the 
uterus, or the urethra ; alone, or variously combined. 

Second Species. Gonorrhoea in the male : seated in the urethra, on the prepuce, 
or the glans penis; alone, or variously combined. 

Gonorrhoea in the urethra is sometimes termed urethritis ; on the glans, balanitis ; 
and on the prepuce posthitis. These last named affections are also termed external 
or false gonorrhoea. 

The mucous membranes of the eyelids, nose, and anus, are also liable to the 
gonorrhceal infection. 

The first symptoms of disease appear in the male at periods varying from a few 
hours to six weeks after exposure — usually from the third to the fifth day. In fe- 
males it commences at so many different points, and is generally so mild in its symp- 
toms, that we can seldom have the opportunity of examining its first development. 
Very often it is not suspected until it affects the urethra, when burning or smarting is 
produced in urinating ; or until the contagion, communicated to the male, leads to an 
examination by the speculum, the only means for arriving at an accurate diagnosis. 

In the male the first symptom is generally a slight uneasiness at the end of the 
penis ; upon inspection there is perceived a little redness around the meatus, the 
lips of which are puffed out, and there is a slight difficulty in passing water from this 
constriction. A discharge, white, straw-colored, turbid, and sometimes even bloody, 
soon makes its appearance. The scalding of the urine, common in this stage, is 
not always felt. The affection is now strictly local, and does not extend beyond an 
inch, or an inch and a half down the urethra. This is termed the first stage, 
and is accompanied with every degree of inflammation, from the mild and almost 



GONORRHOEA, 818 

chronic, to the highly inflammatory, according to the temperament ami habits of the 
patient 
Th.- second stage is characterized by b Bevere Bcalding <>i* the orine, caused both 

by the progress of suppuration ami tin 1 larger Bnrface affected — tin- discharge now 
coming from a point as high as the scrotum, and involving the ducts of tin- glands 
t»t Cow per. An inflammation of the urethra, producing a contraction, with a con- 

Btanl tendency to erections, causes a painful ehordee, and the matter assumes a 
thickened and greenish appearance, and is often tinned with blood. 

In this Btage the inflammation is often violent, and the sympathetic affections se- 
vere. There is a nervons fever, pains in tin; loins and back, sleeplessness, and gene- 
ral disorder, all proceeding however, from local irritation. At this stage abscesses 
may form in the substance of the penis, for which prompt surgical treatment is 
r< quired. 

The third stage commeuccs when the inflammation reaches the prostatic portion 
of the urethra, embracing the entrance of the bladder, the prostate gland and its 
ducts, the seminal ducts and vcsicula) scminalcs. At this stage, the patient may 
be affected with tenesmus, retention of urine, inflammation of the bladder, of the epi- 
didymis, the spermatic-cord and vas deferens, gradually involving the whole of the 
iid scrotum, and producing the sympathetic buboes, which, however, may 
occur at any period after the first, or primary stage. 

The prognosis of gonorrhoea is one of the most perplexing things in the whole 
ran^e of medical science. Left to itself, it is capable of resolution at any stage, 
without treatment, or it may subside into a chronic form, accompanied by a gleet, 
which seems to gradually lose its infectious character, and which may continue for 
an indefinite period, in spite of all treatment, or may cease spontaneously, or as a re- 
sult of some favorable change in air, diet, or regimen. 

It is difficult, if not impossible, to say when the chronic gonorrhoea, or gleet, abso- 
lutely ceases to be infectious, though this is a question of great importance to the 
patient. So much the greater is the necessity of preventing the appearance of the 
disease, or of curing it in its early stages. It now and then happens that during the 
first stage of the disease, or while much active inflammation exists, a serous effusion 
occurs in the cellular tissue of the penis, usually confined to the prepuce, but some- 
times involving the entire organ, enlarging it as much as thrice its natural size. 



PLATE XXXV. 

FIGURE 1.— ULCERATIONS OF THE CERVIX UTERI. 

This view was taken from a female who had had a discharge for twenty months. She 
attributed it to abortion, which occurred about the period of its first appearance. Her hus- 
band, she stated, had suffered from several venereal complaints. Inoculation was tried on 
several and separate occasions, but the inoculated point healed in twenty-four hours, and as 
we always failed in producing the characteristic pustule, we concluded that these ulcers 
were not specific. 



FIGURE 2. — CATARRH OF THE UTERUS. 

This affection occurred in a young girl, seventeen years of age, who presented a lym- 
phatic temperament. She stated that she had formerly been much used to exercise in the 
open air, but during the last few months she had hardly ever left the house, and lived in a 
very crowded and damp situation. The condition of the os tincae in young females is well 
shewn, but the mucous membrane is paler than usual. The artist has very correctly repre- 
sented the glairy white-of-egg like discharge proceeding out of the os uteri, in which we 
occasionally meet with globules of pus, a secretion very different from those witnessed in 
the other forms of blenorrhagia. 

214 







i 



/ 




v. 



- 






CMAI'TKIt XIV. 



CONOltKIKK \. — TRE \TMKNT. 



; in i vw. — No antidotes known. — Police regulations. — Ablutions. — Abortive treatment. — An 
antiphlogistic regimen, and avoidance of all excitement. — When the disease is first established it may 
be checked by astringent injections. — Revulsive treatment. — General and local depletion in the more 
advanced Btagea. — Purgatives. — Cubebs. — Balsam Copaiba. — Antimonials. — Ulcers and their 
treatment. — Inflammation reaching the bladder : its treatment. — Gonorrhcea in women : treatment. 
Some complications requiring different treatment. — Injections of the uterus. — Tampon. — The di- 
agnosis of Gonorrhoea in the female very difficult. 



With the truly enlightened and philanthropic surgeon, the first inquiry in regard 
to any disease must he — how can it he prevented 1 This is termed the prophylactic 
treatment, and demands our first attention. 

We do not know of any substance, which, taken into the system, is an antidote to 
the infection of gonorrheal matter. Such an antidote has long been sought for, and 
its pretended discovery has been often announced, but we have no good reason to 
believe thai any of these pretended prophylactics are infallible. It is natural to sup- 
pose that a small dose of the essence or extract of cnbebs, or of turpentine, might 
have snch an effect, but it is a matter which could only be tested by a series of 
difficult or nearly impossible experiments, for we are not to expect that men will 
voluntarily submit themselves to infection, merely to oblige a scientific experimentalist. 

The condam, if perfect, is, of course, an absolute preventive. To ensure this 
however, it cannot be used the second time, without having been thoroughly washed 
in a soap of a very caustic kind. Persons who use these instruments, which in spe- 



216 GONORRHCE A. — TREATMENT. 

cial cases are recommended by surgeons, both to prevent conception and infection, 
purchase them by the package, and run no risk from a second use. 

But in a great majority of cases, were ablution with soap and water, and the pas- 
sage of urine, practised immediately after connexion, and that connexion brief, and 
fulfilling its chief object, there would be very little danger. I am so satisfied of this, 
that I believe it to be quite possible to eradicate this disease in the space of a couple of 
years, by proper police regulations. They only who know how frequent this disease 
now is, and what pain, trouble, expense, and distress it causes, can properly appreci- 
ate the advantages of such a course as could easily be taken by the proper authorities. 

There are doubts as to the right to pass laws, restraining men from indulging in 
their various appetites. It is certain that penal laws against drinking, or fornication, 
must be dead letters upon the statute book, but a law which would prevent one 
person from poisoning another, by the spread of an infectious malady, is manifestly 
just ; and the wilful communication of such a disease, should be treated as a mis- 
demeanor of a very serious grade. But I have already dwelt upon this subject, in 
connexion with syphilis. 

In the absence of the proper legal remedies, the only known prophylactics are 
such as I have mentioned above. 

Next in importance to the preventive treatment, is the abortive ; and in this dis- 
ease, so difficult to cure in its later stages, this treatment is peculiarly important. 
It is indeed of the greatest consequence that it should be cut short at the outset. 

For this purpose, the first indications are absolute rest, quiet, removal from all 
causes of excitement, sexual and otherwise, total abstinence from spirits, wines, and 
fermented liquors, from spices, and nutritious or high-seasoned food — in short, a 
most thorough and perfect antiphlogistic regimen, and a brisk purge of senna and 
salts. This alone has often prevented the development of the disease, when its first 
symptoms had made their appearance. These symptoms consist, in such cases, of 
a slight itching of the urethra, especially in making water ; a sense of weight in the 
penis and scrotum ; a frequent inclination to urinate ; and at length a little redness 
of the meatus, and an increased secretion of mucus. 

All these symptoms, however, may be simply the result of excitement. It does 
not at all follow that there will be a gonorrhoea ; still, such signs are enough to put 
the patient on his guard ; and it may be, that but for errors of diet, the disease 
would never be further developed, even where there is no doubt of exposure to the 



GONORRHOEA, TRB \tmi:\ i Bl" 

ction. A strictly antiphlogistic diet — a lenteo fast with total abstinence from all 
malt, vinous, distilled tiquorSi and cider) ami refraining from warm baths, ami ever) 
thing thai can either excite or enervate, from fatigue and exposun — give the best 
chance of avoiding the evolution of the disease, or. of easily curing it when indu- 
bitably manifested. 

Bnt, in vi<\\ of the dangers of delay, and of the fad that tin- severity of the affec- 
tion is in proportion to its continuance, ought we to wait for the commencement of 
the muco-purulenl discharge, before attempting to check it by more decided treat- 
ment ! Where the patient has been exposed to a hazardous connexion, and whi 
the premonitory symptoms exist, 1 am decidedly of opinion that no time should be 
lost. The disease at this time, or rather the infected surface, is very small in extent 
— not extending more than an inch, possibly less than that distance, up the urethra. 
'I nero are now several modes of treatment. In a number of cases, and with very 
tew failures, I have found that injecting into the urethra, every half-hour, a solution 
of the sugar of lead and the sulphate of zinc, and continuing them for twenty-four 
to forty-eight hours, lias usually been sufficient to cure the disease. Frequent injec- 
tions of warm water in the acute stage is always highly beneficial. Injections of a 
solution of nitrate of silver, from two to twelve grains to the ounce, according to 
circumstances, are strongly recommended by Carmichael, and other surgeons. I 
however, have not found in them the benefits T was led to expect; and 1 am satisfied 
that the most successful way of using nitrate of silver in chronic cases, is to effect a 
cauterization, and for this purpose we must use either the solid stick, guarded by a 
proper holder, or the solution as strong as it can be made, consistent with the ne- 

wary degree of fluidity. It is certainly my belief, that a bold, thorough cauteriza- 
tion of the urethra, to the extent of diseased surface, followed by antiphlogistic 
treatment, proportioned to the inflammation, would in every instance, check the dis- 
in its earliest slages. 

What is termed the revulsive treatment, is much practised in the French hospitals. 
It consists in the application of from twenty to forty leeches to the perineum, accord- 
ing to the strength of the patient, with powerful doses of copaiba, cubebs, and similar 
medicines. This treatment, Ricord thinks will always cure gonorrluea in from three 
or four to fifteen or twenty days, the proper regimen and diet being strictly ob- 
served. 

When the disease is of a mild type, without pain or inflammation, it may often be 
cured with astringent injections, without resorting to any other remedies. 



218 GONORRHOEA. — TREATMENT. 

Whatever the treatment, the bowels should be kept open, and for a drink, the 
patient may have a tea made of barley, flax-seed, mucilage of gum-arabic, or some- 
thing similar, with the addition of small doses of the nitrate of potash, which cor- 
rects the irritating qualities of the urine. Drinking large quantities, so as to fatigue 
the urethra by a frequent passing of urine, is objected to by many writers. This is 
all nonsense ; it is perfectly evident that a frequent cleansing of the urethra, either by 
simple injections, or the more natural process of urinating, must be calculated to do 
good and advance the cure. 

Besides the use of injections of the nitrate of silver, in all proportions, from one 
grain to the ounce, up to a powerfully cauterizing solution; and of the sugar of lead, 
sulphate of zinc, sulphate of copper, tannin, &c, a solution of the iodide of iron,' 
varying in strength from one to eighteen grains to the ounce, has proved in my prac- 
tice sometimes successful. 

Before proceeding to the consideration of the treatment to be pursued in the 
secondary stage, I must mention one remedy, on which I believe great reliance may 
be placed, which is the introduction of a roll of lint, dry, or saturated with a mild 
resolvent solution, either after a cauterizing injection, or one of a more simple char- 
acter. This may be managed in several ways. The easiest would be, perhaps, to 
introduce the roll in a silver tube, to which I have adapted a wire with a blunt fork, 
that straddles a fold of the tent. The wire holds the lint while the tube is with- 
drawn, after which the wire is removed with ease. This appears to me the most 
convenient method. 

Keeping open the urethra of the male cannot fail in promoting a cure, as the 
progress of the disease is maintained by the contact and irritation of affected sur- 
faces. This lint may be removed as often as necessary, and fresh rolls introduced. 
I do not despair of yet discovering a remedy, which, appfted in this, or some other 
manner, shall deserve to be considered an absolute specific in all the stages of this 
disease, in which it is confined to the urethra. 

Until such a discovery is made, we must rely upon the local applications and re- 
vulsives mentioned above. 

The second stage of gonorrhoea — that attended by a more extensive suppuration, 
violent scalding, frequent and almost constant erections, painful chordee, and some- 
times bleeding more or less violent from ruptures of the urethra, comes on at no 
definite period. It may occur in a week, or not for a month. When this stage is 



NO&RHCBA. i 'RE \ PMBNT B19 

full) formed, with its inflammatory tendencies, and especially if the Btippurating pro- 
c< as shall have extended to tbe bulb of the urethra, injections can be of but little ose, 
and may aggravate the symptoms. 

Should the patienl require it. general as well as local depletion, or at all events, 
entire rest and a Btrictly antiphlogistic regimen must be insisted on. The local ab 
straction »>i' blood, b) leeches, continuously, and in considerable quantities, if strongly 
recommended. The patienl must be Kept as free as possible from all excitement, 
from lascivious ideas, and in as low a temperature as is consistent with comfort. 

The tendency to erections, with ihe exquisite pain of their attendant ehordec, in 
this Btage may be controlled by pills of opium and camphor, cither taken in the usual 
manner, or pushed up the rectum. And the anti-gonorrhceal medicines, particularly 
copaiba, when it disagrees with the Stomach, may be given in this way very conve- 
niently, in the form of capsules. Doubtless it is better that they should be taken 
into the stomach, but in many cases that is impossible. 

Injections of cold water, but more especially those made from a decoction of 

poppy-heads, as warm as they can be borne, and the solid contents of the decoction 

formed into a poultice and externally applied to the penis, have given me the most 

happy results, rapidly allaying the violence of inflammation, and when chordee ex- 

1 at the same time, quieting that symptom. 

1 have heretofore expressed my unwillingness to proceed to general blood-letting 
in tin se diseases, except where indicated by excessive fulness; preferring, generally 
to control the circulation by nauseating doses of antimony ; and perhaps nothing is 
more likely to prevent erections, and their attendant pain and irritation, than the 
nausea thus produced. 

Dm in*: the inflammatory action which attends the progress of the disease in the 
lower portion of the urethra, abscesses are sometimes formed. These should be 
watch* d with great care, and the moment fluctuation is distinctly felt, they must be 
opened outwardly, and where the skin is not adherent. These abscesses, if not thus 
opened outwardly, may form an opening into the urethra, produce infiltration of the 
urine, with its attendant irritation, and fistulae, which are by all means to be avoided. 

The hemorrhage, caused by a rupture of the urethra, sometimes produces a fa- 
vorable result; but at others it returns at every erection, and becomes so serious as 
to require surgical remedies. Preventing erections, and keeping the parts elevated 
and cool, may be sufficient. If not, we may resort to cold lotions, compressions, and, 



220 GONORRHOEA. — TREATMENT. 

if required, the introduction of a bougie, which may be allowed to remain for one or 
two days, or even longer, until the hemorrhage is arrested. 

When the inflammation has been controlled, we must resort to the anti-gon- 
orrhceal medicines, of which I shall speak more particularly hereafter. Alone, or in 
combination, they may effect a cure ; or each may fail in its turn. We may also, 
when not contra-indicated by inflammatory symptoms, resort to injections; but 
without any promise of absolute success. Surgery is no where more at a loss than 
here. In one instance where a gonorrhoea had for twelve months resisted every 
mode of treatment, with the assent of an intelligent patient, I injected nearly the 
whole length of the urethra with the strongest possible solution of nitrate of silver, 
which was retained for some moments. The operation was by no means as severe 
as one might suppose, there having been instantly formed a cauterized surface. Af- 
ter cleansing the passage, by urinating, a bougie was introduced, and worn for several 
days, and the cure was complete. 

I have much faith in the efficacy of keeping the urethra open, and free from con- 
tact with itself; which plan, with the free cauterization, produced the cure in the ob- 
stinate case above mentioned. 

In the third stage, which is however but a name for the gradual progress of the 
disease through the length of the urethra, the inflammation extends to, and perhaps 
into the bladder, affecting the prostate gland, the glands of Cowper, and the epidi- 
dymis, as also the rectum. The result is a distressing tenesmus, a retention of 
urine, painful erections, with a liability, if the symptoms are not immediately relieved, 
to an ulceration of the bladder, suppurations of the glands, fistulse, infiltrations, and 
gangrene. 

With a patient in such a condition, brought on by exposure, carelessness, excess, 
or bad treatment, the surgeon must resort to prompt measures ; the inflammation 
must be reduced, by general and local treatment. Leeches may be applied to the 
perineum, followed by wet cloths ; an injection of fifty drops of laudanum in a wine 
glass of warm water, may be thrown up the rectum, or a pill of opium placed there 
to control chord ee and tenesmus ; under this treatment, as inflammation subsides, 
the spasm ceases, and permits the passage of urine ; but if not, we must resort to 
the catheter. A curved gum-elastic instrument, of a middling size, lubricated with 
an ointment containing extract of belladonna, should be introduced very slowly ; and 
may be allowed to remain, while the inflammation is still combated. In this stage, 



OONORRHCEA TOBATMENT. 221 

• 

frictions with landannm, and emollient cataplasms, may !»«• nsefol, bm the treatmenl 
here is more general than specific. 

After the acute stage has been snbdned, ire may resort to the anti-gonorrhceal 
medicines, with cold and saline baths, ionic lotions, q more general diet l)iit not 

slightest excess, and an attention to such a regimen as shall promote the most 
healthy condition of the system, and the fullest and most free action of the vital 
functions. ^ 

"We are never to forgel that here is no virnlent poisoning of the blood, but a dis- 
d state of a single tissue, which nature is constantly endeavoring to restore to a 
healthy standard. In the chronic form, which the discharge maintains for a long 
period, running into an annoying gleet that may last for years, sea bathing, and 
perhaps the tonic air of the sea shore has been of great benefit. The mineral 
waters are also highly recommended. 

In one case, where several sailors went to sea, with such discharges, they all took 
to chewing oakum, and attributed the cure which followed, to the tar it contains. I 
am not prepared to say that tar-water, as a daily drink, might not promote a cure 
in the obstinate cases we often meet with ; and I recommend its trial in our hos- 
pitals. If, however, it was the sea voyage, the regular life, and bracing air, which in 
many cases promotes so much the health of the system, then we are to recommend 
a sea voyage. 

Gonorrhoea in women, is a disease comparatively mild in its symptoms, and of 
easy cure. It is scarcely noticed in the first stage, and liable to be confounded with 
other discharges, so that the surgeon has not often the opportunity of cutting short 
the disease, by the treatment termed abortive. When it is observed in the first 
stage, existing in the vagina or uterus, astringent injections and applications may 
be effectual ; or if the disease exists in the urethra, it may be cured by cubebs and 
copaiba. The principal means of cure, are, antiphlogistic treatment according to 
the symptoms, cleanliness, by means of baths and injections, demulcent drinks, and 
emollient and narcotic fomentations. 

Perhaps the most effectual means of all, is the isolation or separation of the affec- 
ted parts from each other, and rest. A tampon of fine lint of sufficient size, should 
be introduced into the whole extent of the vagina, and moistened several times a 
day, with a solution of the acetate of lead and sulphate of zinc ; or the vegetable 
astringent lotions may be sufficient. 



222 GONORRHCE A. — TREATMENT. 

There are cases in which the acute stage does not yield readily to antiphlogistics, 
emollients and astringents. In such cases, a superficial cauterization of the parts 
with nitrate of silver injections, or a solution, applied by means of lint, will produce 
astonishing results. After such cauterization, the sides of the vagina must be kept 
apart by dry lint, to aid in the cure. In the acute stage, the anti-gonorrhceal medi- 
cines afford no benefit, and may increase the irritation. 

After the acute stage, the treatment should be active, to effect a speedy resolu- 
tion, and to avoid a chronic stage, which may last long and be troublesome. The 
strength of the solution used as injections, or with the tampons, may be increased 
at this time, and will generally produce a cure ; but in many cases, more tonic appli- 
cations must be resorted to, such as a decoction of oak-bark, with equal parts of 
sulphate of alum, zinc, corrosive sublimate, &c, and may be used in succession. 

Should the disease extend to the interior of the uterus, the treatment becomes 
one of extreme caution and delicacy, yet even the internal surface of that organ will 
admit of injections of nitrate of silver, which may be commenced with one grain to 
the ounce, and increased — such injections to be given at intervals of several days. 

The deep-seated portions of the vagina and the uterus, are liable to be affected 
with ulcerations and granulations, which are to be cauterized with nitrate of silver, 
or nitrate of mercury ; or calomel may be sprinkled on the diseased part ; and after 
each cauterization or application, the tampon is to be used as before directed. 

There are a few points more which may deserve the consideration of the surgeon 
in addition to the general principles already mentioned. 

When, from the acuteness of the inflammation, the natural smallness of the va- 
gina, or from virginity, it may be impossible to resort to injections, until the acute 
symptoms have subsided, we must have recourse in such cases, entirely to external 
applications. 

In acute affections of the uterus, emollient fomentations and cataplasms may be 
applied to the lower part of the abdomen. 

Acute urethritis is sometimes accompanied with retention of urine, which, if it 
does not yield, as in most cases, to antiphlogistic treatment, requires the catheter, and 
it must be applied with as little irritation as possible. 

The swelling of the nymphse is sometimes so great, with serous infiltration, as 
to threaten gangrene. Incisions should be made to prevent this : but if it have un- 
fortunately occurred, we must pursue an antiphlogistic treatment, with the local ap- 



TORKIICEA. — Tltti \ I'M i:N I 






plication of extract of opium. I have elsewhere recommended for gangrene the u 

uinaria, externally and internally. Ii ma] !>«■ employed in combination with 
opium. 

Of course many of the applications mentioned above, require the frequenl use of 
the Bpcculum, an instrument of absolute necessity in all female diseases; but it if, 
quite apparent that ii cannot be need in the acute Btage of the disease. 




Tri-valvc Speculum. — The host in use. 



The prompt opening of abscesses, wherever formed, in or around the vagina, 
must not l>e neglected, if we would avoid infiltration of pus into the tissues around 
the rectum, and the formation of fistula?. These may usually be obliterated when 
first formed, by compression ; but if they do not yield to this, they require cauteriza- 
tion, and the subsequent application of cantharides, to promote granulations. 

Inflammation of the ovaries may exist as a complication of gonorrhoea in women. 
It requires antiphlogistic treatment, and general and local depletion, with laxatives. 
After the acut( Misters applied to the inside of the thighs act as revulsives, 

and frictions with mercurial ointment in the iliac region, appear to act as resolvents. 

When injections of the uterus are followed by hysterical attacks, they are to be 
treated with auti-spasmodics, and symptoms of cerebal congestion maybe met, either 
1>\ the abstraction of blood from the arm, or the application of cold to the head. 
The use of the douche bath, or a large stream of water falling on the head with 
considerable force, is used by many in preference to the lancet. 

Gonorrhoea in females, as in males, is sometimes, though rarely, followed by a 
chronic discharge from the urethra. In these eases injections must be made use of 
as in males — with the same instrument — the entrance to the bladder being guarded 



Jfr 



224 



GONORRHOEA. — TREATMENT. 



by pressure with the finger passed up the vagina, or it may be cauterized by solid 
nitrate of silver, with the aid of a suitable holder. 

Emollient fomentations and injections should be tepid — but resolvents, astrin- 
gents, and tonics, should be applied cold. The injections must be made with a 
female gl iss syringe, which, for obvious reasons, is superior to all others, by which 
the injection may be made to penetrate to the whole extent of the vagina. In chil- 
dren, or when the hymen exists, we may employ a straight canula with a conic end. 




Speculum Chair. 



The position of the patient is important. It is only in a recumbent posture, with 
the pelvis elevated that the injections will reach every part of the vagina. 

Injections of the uterus require a proper position, the use of the speculum with a 
strong light, and a glass or silver syringe, furnished with a long sharp pointed 
nozzle. It is necessary in using highly astringent or caustic injections, to wash the 
uterus afterwards with a simple fluid — and an ingenious double syringe has been 
contrived for that purpose. 

The tampons are made of a roll of lint, large enough to fill, without distending 
the vagina. After injection, and moistening them with the fluid, they may be 
applied either by the patient or the surgeon, with or without the speculum, but much 
better with it. 



04 IN0RRHCB4 —THE kTMBNT. '-'-'> 

The cure ii t»> be followed by injections of cold water, except, for i few days 
before, after, and during the menetrnaJ evacuation; at winch time i Jh application of 
cold water, is dangerous, and bai sometimea proved fatal. 

The Bpecnlnm chair i> reiy convenient The diagnosis of gonorrhoea in the 
female is a matter of extreme difficulty, and is only accompanied with tolerable cer- 
tainty, when great experience in vaginal and uterine disease - ia anited with the fre- 
quent and skilful application of the speculum. When certain peculiar erosions 
Or superficial ulcers may be -ecu on the mUCOUB membrane covering the cervix uteri, 
mere is little doubt that the disease is a true gonorrhoea. Leucorrlueal dischargee 
in females of undoubted virtue have produced upon their husbands severe balanitis 
and even urethritis. 

it may be the best plan, iii regard to all delicate diseases, to give a patient the 
benefit of our doubts, according to the maxim of law, so far as our communications 
to third parties are concerned ; while we should have from our patients, the most 
unreserved confidence. Indeed, people are too apt to trifle and tamper with their 
medical advisers, in regard to the causes of disease ; and it sometimes requires the 
cross-examining powers of a good lawyer, to get at facts, on which the very life of 
the patient may possibly depend. 



PLATE XXXVI. 

FIGURE 1. — BALANITIS. 



The character of Balanitis, may, with advantage, be studied in this plate. It was im- 
possible to say if sexual intercourse, or want of cleanliness was the cause. The general 
erysipelatous redness of the glans is well seen, and the excoriated appearance so often to 
be met with in this affection. 



" - '•"" FIGURE 2. — VEGETATIONS. 

The subject of this complaint was a young man twenty-four years of age. He states 
that he never has had either gonorrhoea or chancres. The characters of the complaint are 
well seen ; the clusters of the granules are very florid, each granule presenting a conical 
appearance, though collected into masses. 



FIGURE 3. — ECZEMA. 

The appearances, as seen in this plate, are very characteristic of the affection, namely, 
the exudation of a serous fluid forming little scales, and the crevices are distinctly seen run- 
ning between these little lamella?, resulting from the drying of the exuded fluid. The his- 
tory of the case was obscure ; the patient advanced in life. 



FIGURE 4. — HERPES PREPUTIALIS. 

Herpes, in its various stages, is delineated in this plate. Commencing as a vesicular 
disease, its vesicles may ulcerate, and assume all the physical characters of chancre. The 
five or six vesicles will be seen on distinct patches of inflamed skin, differing, in this respect, 
from all other vesicular eruptions. 

226 










/ 



CHAPTER XV. 

BALANITIS AND POSTHITIS. 

• 

Their Definition. — The symptoms. — The common causes: treatment. — Cauterization. — Astrin- 
gent ami anodyne lotions. — Antiphlogistics. — Operation for Phymosis. — Some of the consequences 
of Balanitis when improperly treated. — Gonorrhoea common to both sexes. — Of the eyes : men 
and infants most liable to it. — Caution. — Treatment. — General and local antiphlogistic measures. 
Cauterization. — Narcotics. — Chemosis : treatment. — Excision. — Scarification . — Cauterization. — 
Issues. — Gonorrhoea of the mouth and nose: of the anus: treatment. 

Balanitis is a kind of external gonorrhoea, situated on the surface of the glans 
penis : a similar affection of the prepuce is called posthitis. 

These affections are characterized by redness, a muco-purulent secretion, with or 
without excoriation. Though separately designated, they are generally complicated, 
or rather the entire surface is affected. 

This disease will scarcely occur, except in patients who have a partial degree of 
natural phymosis; for where the glans are freely and habitually uncovered, the sur- 
faces become hardened against the causes which produce it. 

The presence of vaginal secretions of a more or less irritating quality ; the mens- 
trual fluid ; the matter of gonorrhoea; the secretions of th< glandulae odoriferae, or 
filth of any kind, lodged beneath the prepuce, act as irritants, and are the most com- 
mon causes of this affection. On account of the generally existing phymosis, it is 
not always easy to distinguish between chancre and balanitis. When the prepuce 
can be drawn bark, the redness, swelling, and excoriated surface of the glans, or 
the prepuce, may easily be distinguished from syphilitic ulcerations. 

227 



228 BALANITIS AND POSTHITIS. 

The treatment is very simple. A single cauterization will sometimes produce a 
cure. If not, it must be repeated. All inflammation is to be allayed by the usual 
methods. Compresses wet with cold water, or a solution of sugar of lead and zinc, 
are very useful ; or anodyne lotions may be employed. When the inflammation is 
accompanied by phymosis, or paraphymosis, active antiphlogistics are required, with 
fomentations, and emollient local applications. Opium and camphor, by the mouth, 
by injections under the prepuce, and in enemata, are serviceable in preventing an 
attack of gangrene. An operation for phymosis should not be resorted to, unless 
of absolute necessity to prevent gangrene, while there is any doubt in regard to a 
syphilitic complication. 

Cauterization, carefully performed, with a stick of the solid nitrate of silver, and 
the interposition of a piece of soft linen between the surfaces of the glans and pre- 
puce, is generally sufficient. An astringent powder is sometimes found to answer 
better than an astringent lotion for the subsequent applications. 

Balanitis, when improperly treated, may produce enlargement of the sebaceous 
follicles, vegetations at the base of the glans, thickening and hypertrophy of the mu- 
cous membrane, adhesions between the glans and prepuce, and, according to some 
authors, cancer of the penis, as well as paraphymosis and phymosis already men- 
tioned. It may also produce the sympathetic affections of the glands of the groin, 
the epididymis, &c, of which I shall speak hereafter ; and I have also preferred to 
treat separately the surgical operations necessary in venereal diseases — their conse- 
quents and concomitants. 

GONORRHOEA COMMON TO BOTH SEXES. 

I have already mentioned the fact that gonorrhoeal inflammation may attack the 
mucous membrane lining the eyes, nose, mouth, anus, &c. ; and though these 
affections are comparatively rare, they are still of sufficient frequency to demand a 
brief and separate notice. 

Gonorrhoea of the eyes — Blenorrhcea oculi — is more common in men than wo- 
men, and more frequent in infants than either, who are attacked immediately after 
birth, from infection received from the mother during parturition. There appears to 
be little doubt that in adults, as well as in infants, the disease arises from the direct 



i; ILANITTS and POSTHITIS. 829 

lication of gonorrhoea! m itter to the conjnn Jtiva ; an 1 it is m >re coram m in m in 

than women, Bimplj b cause they are more apt t<> carry the matter to the eyes, <>r 

other parts subject to infection, than females. The idea that these affections are 

npathetic, i> opposed by their infreqnency, by He impossibility in cases of infants. 

and by the circumstance thai ;i sympath) would be more general. 

\-= the consequences of the gonorrhoea] opthalmia arc frequently of a very serious 

nature, the causes of it should be most carefully avoided. The gonorrhoea! poison 

Ktremely Bubtile. It lodges in the slightest crevices, as cracks in the skin, and 

the space mi ler the nails ; and the patient with a gonorrhoea cannot be tOO careful 
not to soil his fingers in the first instance, and in not communicating the infection 
by rubbing his eyes in the second. 

For the same reason, when the infection has taken place, the treatment should he 
prompt and energetic. It consists, first, in general and local antiphlogistic treatment. 
If the patient is so robust as to require it, he may he hied from the arm, and have 
leeches applied to the nostril, temple, and around the affected eye, avoiding the lids. 
The eye-lids should then he everted, with the least possihle irritation, and the whole 
surface of the conjunctiva slightly, but carefully cauterized with a stick of nitrate 
of silver, after which the caustic matter must be washed away by a careful injec- 
tion of cold water. Compresses, dipped in a cold decoction of poppy-heads, may 
then be laid over the eye. Should there be deep-seated pain and inflammation, the 
extract of belladonna may be applied to the nostril, and lower margin of the orbit. 

A chemosis, threatening the strangulation of the cornea, requires immediate treat- 
ment, either by cauterization or excision. If a simple cedematous chemosis, it may 
be easily raised with the hooked forceps, and removed by curved scissors; but if 
phlegmonous and indurated., scarifications only can be used, and they arc uncertain 
in affording relief. 

The cauterizations with the nitrate of silver, are the first, second, and last remedy, 
but they should be aided in every possible manner. A seton, or, as I prefer, an issue 
with the pea on the back of the neck, and frequent purgatives, are very efficacious, 
and an eye-wash of nitrate of silver, fone grain to the ounce of water) may follow 
up the cauterizations. 

The anti-gonorrheeal medicines, as cubebs, copaiba, &c, have no influence on 
this affection, nor in any other, except the urethra be its seat. 

Gonorrhoea of the mouth and nose, is extremely rare, but it is somewhat more 



230 



BALANITIS AND POSTHITIS. 



frequent in the anus, especially in females. In the latter affection the bowels must 
be kept open, with whatever antiphlogistic treatment is necessary; and baths and 
emollient fomentations are useful auxiliaries. Slight cauterizations with the nitrate 
of silver, solid, or in solution, is most of all to be relied upon. 

It' really appears that the means most to be confided in, when treating any variety 
of venereal disease, in its early stages, is the application of a powerful caustic to the 
diseased surface, destroying the virus, or producing, .with a new surface, a healthy 
action- 



CHAPTER XVL 
VARIOUS MEDICINES FOR GONORRH(EA. 

Balsam Copaiba : Its mode of action — different modes of administration — its combinations with other 
medicines. — Cubebs : Its combinations and forms. — Turpentine. 

In speaking of a disease so common, so often difficult to cure, sometimes so de- 
plorable in its results, and where there is such a variety and uncertainty of opinions 
in regard to treatment ; I have thought proper to add a few remarks respecting the 
medicines and management most worthy of our consideration — the results of gene- 
ral experience ; of which results however, science can make no boast. The most 
important specific remedy is balsam of copaiba, which appears to produce salutary 
effects in al leasl two different modes. When it acts, as it sometimes does, and if 
n in very large doses may nearly always do, upon the bowels, giving rise to 
diarrhoea, its modus operandi is denominated revulsive. A new centre of fluxion is 
established in the intestines, and an irritation, or perhaps inflammation of an ordinary 
kind, takes the place of one of a specific nature in another and distant situation. In 
this way, its action is analogous to counter-irritation by blisters and other remedies 
of this class, and the cure possibly follows on the same principle. The balsam may 
be combined with purgative medicines, less offensive to the stomach, by which ca- 
tharsis is obtained more agreeably, and the same chief purpose accomplished. It 
is, indeed, alleged by some of the highest authorities, that the purgatives in common 
. will fulfil the indications just as well as if copaiba be employed, cither alone or 
in conjunction with them. Such is the prevailing theory respecting revulsive action 
of balsam. I am inclined, however, to entertain a view somewhat different. Giving 

231 



232 VARIOUS MEDICINES FOR GONORRHOEA. 

full credit to the consequences of counter-irritation, I cannot help thinking that it 
also produces its usual specific effects by entering the torrent of the circulation. 
We thus have two causes concurring, that may, in certain peculiarly obstinate cases, 
develope a new action in the diseased membrane, which, singly, nether one would 
be able to establish. I have known rapid cures occur, when balsam has been joined 
to a purgative, that it was quite unable to accomplish alone. 

It is thought by some, for whose opinions I entertain a very high respect, that, 
although purgation will suspend the urethral discharge, yet there is a great liability 
that it will return, when medication has ceased, and the affection is supposed to be 
cured. My own experience does not corroborate this view. But, although I believe 
the plan to be a good one, looking merely to arresting the disease, I do not fre- 
quently resort to it, in consequence of the pain and debility that the patient is thus 
made to suffer, and his necessarily great repugnance to such rough treatment, which 
he does not fully comprehend the advantage of. 

The other mode in which balsam acts, is .entirely through the kidneys. It is im- 
possible to explain the manner in which it allays the blenorrhagic inflammation. 
There can be no reasonable doubt that in its passage through the system, the 
medicine undergoes some peculiar change, fitting it for the specific effect that is 
accorded to it. This fact would seem to be demonstrated by employing the same 
remedy in the shape of an injection. When used in this way, no good has resulted ; 
and this method, therefore, has been abandoned for the more efficacious one of 
internal administration. 

Balsam copaiba is contra-indicated during the acute stage of severe inflammation, 
which should first be reduced by purgatives, leeches, fomentations, and in short, the 
general antiphlogistic treatment. Its dose should be modified according to the stage 
of the disease, and its constitutional effects on the patient, and it may be exhibited 
in varfcms combinations, or alone. 

The mixtures and preparations are, for the most part, excessively nauseous, and 
the elegant form of capsules, now universal, is to be preferred to all others, but it 
may also be administered without much difficulty, in lemonade, or lemon soda. 

The only combinations which appear of any use, are those with opium or astrin- 
gents, when we wish to prevent its action on the stomach and bowels and with 
diuretics, to aid its passage through the kidneys ; and the observations of Ricord, in 
regard to its impotence in the cure of any other than the urethral gonorrhoea, would 
indicate that it is to this point we must direct its specific action. 



\ IR10US M EDI* IINES I '< >H Q< >N< (RRHCB \ 

Dr. Wallace, whose experience ia entitled to reBpect, iu spite of his theoretical 
errors, preferred ii> use u in combination with cnbebs. 

Some French surgeons give copaiba in doses, of from half an onnce to an onnce, 
nighi and morning, :u the commencement. ML Delpech cured lour hundred cs 
1>\ giving two drachms and npwards for a dose, throe times a day, with general 
hired ng, when required by inflammation. Rossignol cured three hundred ca 
of all kinds, by no oilier treatment or regimen, than large doses of nncombined 

COpaiba. In such treatment, the specific effect through the kidneys. Madder and 

urethra, m iv accompany or follow the revulsion, which in most cases must be 
produced by the irritation of large doses on the bowels. 

The combinations spoken of, as with opiates, astringents, or diuretics, may be 

m tde in the stomach, by giving the other remedies immediately after the capsules; 
or they may be made in mixture or pills, when given in that form. 

W hen copaiba is not tolerated in the stomach, it may be given in proportionally 
large doses as an enema. It is best taken at night, after an evacuating injection, 
and iu combination with opium. The patient must be in a horizontal position, and 
retain the injection as long as possible, to derive any benefit from it; two or three 
capsules at a time passed up the rectum will sometimes cure a gonorrhoea better 
than any other mode of administration. 

The next medicine is cubebs, and it is given either alone, combined, or alter- 
nating with copaiba, in large or small doses, under similar circumstances, and with 
similar results. In chronic gonorrhoea and gleets, it is given in combination with 
iron. It is pleasanter to take than the copaiba, and may be used in the simple 
powder, pills, electuary, syrup, or lozenges. The oleo-resinous extract of cubebs, 
obtained by a double distillation, is a concentrated and pleasant form of exhibition. 

In substance, the dose of cubebs is from a scruple to two drachms. This is com- 
paratively a modern remedy in Europe and America, although it has long been em- 
ployed for the same purpose in the eastern world. If it can be obtained fresh, it is 
perhaps quite equal to copaiba ; but the volatile matter upon which its virtue chiefly 
if not entirely depends, unless great care be observed, is dissipated in the air, and 
the substance remaining is very nearly inert. Cubebs, from this circumstance, very 
often disappoints the expectation of the practitioner, and it hence has fallen into un- 
merited neglect To use it successfully, it should be powdered at the time of pre- 
scribing it, and it ought to be given in full doses, or as largely as the patient can 
bear without causing uneasiness. 



234 VARIOUS MEDICINES FOR GONORRHOEA. 

The curative action of this medicine I suppose to be identical with that of copaiba, 
as some chemist has lately ascertained, on subjecting it to an analysis, that they both 
possess a similar principle, in which the virtues of each, perhaps, mainly reside. 

Turpentine, in its various forms, has been much used in this disease, and when 
other medicines have failed, it may be resorted to. I have known it, some- 
times, produce the happiest effects, in cases which had long resisted all other 
means. 

In protracted forms of chronic gonorrhoea, preparations of iron, chalybeate waters, 
iodine combined with iron, and cantharides, are all given as stimulants, tonics, and 
alteratives. External revulsives, as blisters on the insides of the thighs, frictions 
and vapor baths, have also arrested obstinate discharges. 

It is proper to say that mercury has no specific action, and can only be beneficial 
in those rare cases, in which syphilis is a complication, or where a prottacted inflam- 
mation has produced thickening and indurations. Quack remedies for gonorrhoea, 
containing mercury, can be of no advantage, though the disease may get well in 
spite of the remedy. 



CHAPTER XVII. 
SYMPATHETIC BUBO, OR INFLAMMATION OF THE INGUINAL GLANDS. 

\ mii i; the Ik ail of syphilis I have described the bubo that is consequent upon that 
disease ; but there remains another affection resembling it in its early stage, pro- 
duced by different causes, usually less intractable in its nature, and which never is 
succeeded by any constitutional effects. 

The sympathetic bubo is a swelling of the glands of the groin, attaining, some- 
times, considerable size, and is a very frequent concomitant of gonorrhoea. The 
symptoms are too manifest to require description. They are the same in all cases, 
however caused. It is supposed to arise, not from the absorption of virus, but, like 
swelled testicles, from the irritation in some other part. I have repeatedly seen it 
caused by cold. Persons have often presented themselves to me who attributed it 
to working in the water. It is common among fishermen, and a class of bar-keep- 
ers, whose employment exposes them all day long to wet feet, from the frequent 
splashing of watfer in rinsing their glasses. Sometimes it is caused by irritation 
about the feet. I have known it occasioned by corns on the toes. This kind of 
bubo seldom proceeds to suppuration, but I have met with abscesses and ulcers 
formed in this way, intensely painful and difficult to heal. 

Its treatment must be conducted on the usual antiphlogistic plan. Should there 
be, (which is unusual) sympathetic fever, and the patient be plethoric, general bleed- 
ing may be premised, after which blood must be locally abstracted by means of 
leeches. I had one case in which cups seemed to answer a better purpose than 
leeches. The bowels ought to be opened with a brisk purgative, and cold lotions, 
either of whiskey and water, a solution of muriate of ammonia, of sugar of lead, &c, 

235 



236 SYMPATHETIC BUBO. 

should be kept constantly applied. There are times in which warmth appears to 
answer a better purpose than cold, and particularly if there be much pain. Warmth, 
properly directed, may be made to produce the same physiological effects as cold, 
or astringents. The latter diminish the quantity of blood by contracting the ca- 
pillary vessels of the inflamed parts — warmth diminishes it by opening the pores 
and causing a copious exudation of its serum. With such treatment the swelling 
will mostly subside in a few days, and give no further, trouble. The administration 
of mercury is worse than useless in the sympathetic bubo, and it cannot be too 
much reprobated. 



CHAPTER XVIIF. 
ACUTE INFLAMMATION OF THE TESTICLE. 

different designations by which it is known. — Symptoms. — The effects of sympathy upon ditfc- 
renl organs of the abdomen. — Seldom attacks both testicles at once. — Seldom suppurates when it 
i- sympathetic. — Diagnosis. — May be mistaken for strangulated hernia. — The mode of distinguish- 
ing between them. — Causes. — Most common one, irritation of the urethra. — Objections to the 
view of Sir Astley Cooper. — Most frecment when. the inflammation has reached the prostatic portion 
of the urethra. — Injections — the effects. — Effusion of serum and coagulable lymph. — Swelling of 
the epididymis. — Wasting of the testis. — Treatment — purgatives; depletion ; evaporating lotions ; 
fomentations ; poultices ; suspensory bandage ; bandaging the organ ; when abscess is formed to be 
early opened ; opium ; mercurials ; preparations of iodine ; stimulating plasters ; tartrate of antimony. 

This is an affection of the testis, which was known to the older surgeons 
as Hernia I In moral is, and latterly has received several different designations, the 
last of which is that of Ricord, who calls it Epididymite Blenorrhagique. Trans- 
lated into English, as it has been by Mr. Acton, it is Epididymitis. The most in- 
telligible and the most characteristic designation is that which we have placed at 
the head of this chapter, and is sanctioned by Sir Astley Cooper and 8ir Benjamin 
Brodie. I look upon this disease of the testicle as arising from many different 
causes, and frequently as involving the whole gland, and, therefore, the other terms 
that are quoted, lead to contracted and oftentimes false ideas of the pathological 
condition of the organ. 

SYMPTOMS. 

WiiAir.vr.i: may be the exciting cause of this inflammation of the testicle, the first 
symptoms are a tenderness of the spermatic cord, beginning as far up as it can 

287 



/ 



238 ACUTE INFLAMMATION OF THE TESTICLE. 

be felt at the inguinal ring, and proceeding downwards to the epididymis. The 
testicle has a feeling of uneasiness and fullness, but is at first free from pain. It soon 
begins to swell, the tenderness increases, the organ feels hard under pressure, and 
particularly the epididymis. As it grows in size, its weight drags heavily on the cord, 
and, if the cremaster muscle be weak and the scrotum relaxed, much increases the 
uncomfortable sensations. There is now a constant, dull aching pain, and so much 
sensibility, that pressure can scarcely be endured. Sometimes the spermatic veins 
become greatly enlarged, presenting the symptoms of circocele ; the vas deferens is 
also thickened and painful, and, if the inflammation be the consequence of a disease 
of the urethra, we often have symptoms which prove that there has been an actual 
propagation of the inflammation from the mouth of the ejaculatory duct through 
the vas deferens, along its whole winding extent, to the testis in which it originates. 
There is pain extending down the thigh of the side affected, in the hip, about the 
spinous process of the ilium, in the groin, along the inguinal canal, and in the 
loins. 

Some of these pains are sympathetic. There is perhaps no organ in the body, 
unless it be the stomach, having a more extended set of sympathies than this. The 
disease of which we are treating is often the effect of an irritation in another part. 
The pain in the loins arises from the circumstance that the renal and lumbar plexuses 
of nerves give off the nerves that are distributed through the testicle. From the 
connexion between the same nerves and the nerves of the stomach, through the 
medium of the solar plexus, and with those of the intestines, through the mesenteric 
plexus, sympathetic affections of these organs frequently occur, when there will be 
nausea and vomiting, with colicky pains and flatulence in the bowels, accompanied 
with the most obstinate constipation. Many other organs sympathize in the same 
manner, particularly the bladder, which exhibits symptoms resembling a severe irri- 
tation of that viscus. 

Should the disease arise from gonorrhoea, there will usually be suppression or 
diminution of the discharge, but this is not invariably the case ; and what may be 
regarded as a very curious pathological fact, is the restoration of the purulent dis- 
charge from the urethra, when the swelling of the testicle subsides. 

The disease seldom attacks both testicles at once, but it may be suddenly trans- 
lated from the one to the other, in obedience to the same law that rules metastasis 
in other affections and organs. 



f 



\ci n: INFLAMMATION OF THB TESTICLE. 289 

m 

The violence of the local inflammation often causes severe constitutional disturb- 
ance, and ibe patienl Buffers from a high sympathetic fever, with all ita attendant 
symptoms. 

\t the becinnins of this chanter it is stated, that Ricord denominates the inflamed 

- - i 

icle, epididymitis. Although such a term leads to an inaccurate idea <>t* the 
nt of the disease, because the body of the testicle is involved and swollen, yel it 
is Hue thai the epididymis swells more in proportion than the testis, and is longer in 
recovering from the effects. 

Like the sympathetic huho, and all other inllaminations ol* a similar kind, arising 

from the Buffering of distant organs, it is a very unusual circumstance for this affec- 
tion of the tesiis to proceed to suppuration, when caused by sympathy with the 
urethra. But it" it be the consequence of a direct injury, or he primarily affected, 
tin- prognosis is less favorable, and the testicle may become the seat of a very pain- 
ful and troublesome abscess. 

Dl \ GNOSIS. 

Ai i M«>i < : 1 1 the testicle is subject to many diseases, which, from a superficial inves- 
tigation may be mistaken for the one at present under consideration, yet the dis- 
tinctions are so well marked, that such an error ought never to occur. The only 
difficulty in making out its nature, is when its symptoms bear a resemblance to 
hernia. \s 1 have stated in describing the symptoms, when the disease is severe, 
there is a good deal of disturbance of the stomach and intestines; there is swelling 
of the cord, with much pain in the inguinal canal ; all of which symptoms being 
common with strangulated hernia, may lead to a false diagnosis, and induce the 
supposition that the case is one of intestinal protrusion. 

The history of hernia will lead us to make a correct distinction. It will probably 
have been of frequent recurrence. Its development is sudden, and often directly 
r violent muscular exertion. The swelling makes its appearance from the ab- 
domen, and descends; it is attended with but little ofthe peculiar aching pain of an 
inflamed testicle. Should the case remain one of doubt, it may be resolved by ob- 
taining a free motion from the bowels. For this purpose an active purgative injec- 
tion should be administered, and such other means adopted as will insure intestinal 
action. It' these measures succeed, all obscurity is removed; it cannot be a case of 

strangulated hernia. It may be added that the difference in the form of the swell- 



/ 



240 .. ACUTE INFLAMMATION OF THE TESTICLE. 

ing, and the hardness of the inflamed testicle, will also assist in reaching a correct 

opinion. 

Haematocele, which is a collection of blood in the tunica vaginalis testis, is also 

liable to be confounded with the inflammation of the testicle ; but the distinguish- 
ing marks are, the blow by which the swelling was almost instantaneously produced, 
the ecchymosis with which it is generally accompanied, and the little pain the pa- 
tient suffers in comparison with that which attends acute inflammation of the testicle.* 



CAUSES. 

The most common remote cause of inflammation of the testis, is irritation of the 
mucous membrane of the urethra. In no respect is physiology more at fault than 
in furnishing a reason for this fact. The doctrine of sympathies, or the tendency of 
one organ to participate in the actions of another, to a certain extent, is a profound 
mystery. There is some incomprehensible coincidence between certain distant parts 
of the nervous system, perfectly well ascertained, but which still remains unexplained. 
In the case before us, Sir Astley Cooper says that the testicle and urethra are so 
naturally connected in their healthy functions, that they readily sympathize in dis- 
ease. This opinion I look upon as more specious than solid. Admitting such a 
line of argument, we should expect that the bladder would be subject to sympathetic 
inflammation even more frequently than the testicles. We should expect, also, that 
disease of the kidneys would, in like manner, be a very frequent concomitant of irri- 
tations of the urethra. The facts, however, do not sustain such an hypothesis. Be- 
sides, this mode of explanation should apply with equal truth to an opposite order 
in the series of morbid actions. A swelling of the testicle, or an inflammation of 
the bladder, by whatever cause induced, ought frequently to produce an irritation of 
the urethra. So far as I know this is never the case. There is another pathologi- 
cal phenomenon that I conceive very adverse to this explanation, namely, the sudden 
translation of the swelling of cynanche parotidcea, or mumps, (a specific disease of 
the glands of the throat J to the testes in males, and the breasts in females. Noth- 
ing can be more singular than this remarkable sympathy, and it is impossible to ac- 
count for it on the principle propounded by Cooper. There surely can be no kind 
of functional connexion between these widely separated and dissimilar parts ; and 

* Sir Astley Cooper on the testis. 



ACUTE INFLAMMATION OP THE TESTICLE. -II 

we are, therefore, thrown entirely upon tin* general doctrine of sympathies which 
remain still to oe further investigated. 

All tin- instances in which there is inflammation of the testicle, as an effect of irri- 
tation of the urethra, must not invariably he referred to sympathy. H' the swelling 

happen soon after the contraction of a gonorrhoea, while the irritation is still confined 
to the externa] extremity of the canal, then, beyond donbt it is sympathetic; bn1 

when it happens in the later Stages, after the irritation lias advanced to the pros- 
tatic portion, it is probable that it often springs from an extension of the inflamma- 
tion through the tube leading from the testis to the mouth of the cjaculatory duct. 
Hunter states that hernia humoralis occurred as frequently when the "inflammation 
had gone no further hack in the urethra than about an inch and a half, or two inches, 
as where it had extended further.'' The observations of Hunter are very far from 
coinciding with those made by other distinguished surgeons, and, I may add, with 
my own. They prove the general doctrine of sympathy, but it will not do to accept 
his statement as evidence that the disease is, in all cases, dependent on sympathy 
alone. 

After the irritation of the urethra has existed for some time, and the violence of 
its symptoms has subsided ; when, in truth, the inflammation has reached the pros- 
tatic portion, the disease of the testicle is to be apprehended on account of continuity 
of structure as well as from sympathy. Here we do not grope in the dark. We 
have anatomical reasons for our guide ; for in obedience to the same law which we 
see presidio- in all inflammations, by which the inflammation is diffused, the testicle 
may become implicated, having first tenderness of the spermatic cord, and pain and 
swelling of the epididymis. 

Bnt, it is asked, why are both testes not affected at the same time? Here again 
we are met with a difficulty. Cooper says that the disease of one testicle diminishes 
the tendency to inflammation in the other. Such an explanation is necessarily un- 
s factory, because it is only one step towards the final answer. It does not go to 
the ultimate cause. The question rationally arises — ic/nj does disease have such an 
effect I This mode of replying to the inquiry takes leave of the doctrine of sympa- 
thies, and raises one of antagonisms. We see, besides, that the disease of one testicle 
very often suddenly leaves its original seat, and passes to the other testicle. A metas- 
tasis occurs as rapidly as in gout, or rheumatism, and the reason is just as much veiled 
in obscurity. It does not come within the province of this work to enter into theo- 



242 ACUTE INFLAMMATION OF THE TESTICLE. 

retical speculations, and, therefore, I must refrain from attempting an elucidation of 
this phenomenon, and pass on to the more practical points of the subject. 

Injections have a tendency to produce acute inflammation of the testis, not, as 
Sir Astley Cooper says, "by lessening the discharge from the urethra, and leading, 
thus, to a distended and turgid state of its vessels, by which the inflammation is ren- 
dered more extensive in the urethra," but rather because of the sympathy existing 
between the parts. Are such as he ascribes to them, the known effects of astrin- 
gents ? Do they not, on the contrary, diminish the size of the blood vessels, and re- 
duce the amount of inflammation? Whoever has seen the action of astringents 
on the skin, or on the mucous membrane of the mouth, will, I am sure, agree with me 
in this view. The testicle swells, as I believe, because the inflammation is checked 
in the urethra, before the sympathizing parts have time to accommodate themselves 
to the change which has occurred. What have we but similar facts, when the hasty 
drying-up of established sores about the ears, produces inflammation of the brain ; 
or rapidly checking irritation on the body, disease, perhaps, of some internal organ; 
or healing too speedily, a fistula in ano, a fatal malady of the lungs 1 To my mind, 
the same kind of effects are excited in all these and like instances, by some great 
law of animal organization. I entertain no fear of causing an inflammation of the 
testicle by using astringent injections, when they are employed with sound judg- 
ment; and I conceive that an unnecessary and unjust prejudice has arisen against 
them on account of the improper manner in which they have too often been used. 

Bougies and catheters introduced into the prostatic and membranous portions of 
the urethra, will occasionally cause this disease, although in all my practice it has 
never once happened to me. 

Injury and disease of the prostate gland, from whatever cause, also occasionally 
produce such effects. After an operation for stone, and even in the disease inci- 
dent to old age, it may sometimes be observed. Inflammation of the neck of the 
bladder, or a calculus in it, a stone passing a ureter, have all been known to arouse 
an inflammation of the testicle. Hunter relates a case caused by gout. 

Another frequent cause of this disease, is injury inflicted upon the gland by vio- 
lence, such as blows and bruises. But wounds from cutting instruments are not so 
liable to be followed by severe inflammation and swelling, as the other instances that 
I have specified. 

Changes of temperature upon the whole surface of the body, and the application 



^ m 



act ri; [NFL \mm \ HON OF THE TESTICLE. 2 13 

of cold water to the part, when the hod}- ia heated and relaxed, may be succeeded 
l»\ the same effect Vml, in fine, the excitement <»i"the venerea] appetite, long con- 
tinued, such as toying with females, without anj sexual gratification, is another no1 
unusual cause of inflammation of the testicle. 

o> Till: EFFECTS di INFLAMED TESTICLE. 

A i kiwi i\i efieel is one that is common to all serous surfaces — an effusion of 
am, which, in this ease, is into the tunica vaginalis testis. Such a condition con- 
stitutes what, in another place, 1 have described under the head of hydrocele. As 
this inflammation subsides, however, the water is usually removed by the action of 
the absorbents. 

There is sometimes effusion of coagulable lymph, and adhesion of the testis to 
the sack which invests it. There may also be a thickening of the tunics. 

A swelling of the epididymis is a very common consequence, particularly of that 
form of it dependent upon an irritation of the urethra. It does not appear that effu- 
sion of adhesive matter is often extravasated in the great seminal duct, which, when 
it occurs, proves a circumstance of a very unpleasan feature, as it forms an obstacle 
to the natural function of the part. The effusion seems usually to be in the cellular 
tissue. The globus major is the most frequent seat of disease in the epididymis, 
and when here, it is of less physiological importance than when it takes place in 
other portions of the organ. 

There is only one other effect to which I will refer before concluding what I have 
to say under this head. It now and then is observed, that after the testicle has been 
much swollen, the enlargement subsides, as in other cases, by the action of the 
absorbents, but this decrease is not suspended when the testicle has reached the 
original size, and the absorption continues until the whole organ is removed, 
leaving only a rudiment of it behind. Nothing remains except the tunica vaginalis 
the tunica albuginea, and the septa of the gland, all of which are glued together 
feeling to the touch a little knot, hard and solidified. This is a serious effect, as it 
necessarily destroys the powers of virility, and, should both testes be subjected to this 
process, complete impotency must be the consequence. It is very rare, indeed, that 
this accident proceeds from the sympathetic inflammation, yet it should always be 
borne in mind that such a result is possible. 






244 ACUTE INFLAMMATION OF THE TESTICLE. 

TREATMENT OF ACUTE INFLAMMATION OF THE TESTICLE. 

This being an acute disease, accompanied with much local and often constitu- 
tional excitement, the treatment must be directed on the ordinary contra-stimulant 
plan. If there be much fever, or if the patient be plethoric and robust, it is advisa- 
ble to commence by depleting from the arm, after which blood may be drawn, topi- 
cally, by means of leeches or by scarifying the veins of the scrotum with a lancet. 
This latter mode is in some respects preferable to leeches, for the bleeding may be 
effected without any of the disagreeable accompaniments of applying leeches to 
such parts. It is only necessary for the patient to stand before the surgeon, who 
takes the tumor in his hand, drawing the scrotum so tense that the veins are brough 
to a fixed position, when with the point of a lancet, he divides some of the veins 
transversely, which immediately allow the escape of a considerable quantity of blood. 
The discharge may be promoted by the application of warmth, as by placing the 
scrotum in warm water, or enveloping it in cloths that have been heated in hot wa- 
ter. The scrotum and testicles must afterwards be well supported by a suspensory 
bandage; and if the case be a severe one, it is indispensable that the patient place 
himself in the recumbent posture. This facilitates. the return of the blood through 
the spermatic veins into the general circulation, and diminishes its action in the ar- 
teries by taking off the force of gravitation. 

It is well to give a dose of calomel, in combination with jalap or colocynth. If 
brisk purgation be not obtained by these means, an infusion of senna, sulphate of 
magnesia, and cardamons, or any medicine which will produce copious watery evacu- 
ations, ought to be administered. Until the swelling subsides, the bowels must be 
properly attended to. 

Cooling lotions should be kept applied to the parts. Diluted alcohol, vinegar and 
water, a solution of the sugar of lead, of hydrochlorate of ammonia, in the propor- 
tion of two drachms to a quart of water, or the acetate of ammonia, are all useful, 
and any one, or several, may be tried, as may be thought expedient by the practi- 
tioner. 

When the active inflammation is subdued, warm poultices and fomentations are 
to be resorted to, and will rapidly reduce the swelling. The heat thus applied, has 
the effect of stimulating the absorbents, to remove what has been effused by the in- 



aci ti: im'lwimatiii.n OF THE TESTICLE. 245 

flammatory process. Tho only rale to be observed in making the poultices, is to 

take rare that they be not too thick and heavy. Warmth and moisture being the 
object in view, whatever will accomplish this end may be employed for the purpose. 

In some cases it may be necessary to do more than all this, and emetics, or nau- 
seating doses of the tartrate of antimony may be demanded. 'Phis medicine fre- 
quently acts like a charm, arresting the inflammation and "reducing the swelling," 
Being Hunter's words, "almost instantaneously." 

If there be mnch irritability in the patient, the best plan is to resort to opium, 
either in pill or Dover's powder. 

Compression has been adopted with the most marked success, even in the early 
stage of the disease. The plan seems to have been devised in the Pennsylvania 
hospital, as long ago as the beginning of the present century, and with the happiest 
effects. It has lately been revived in Europe, and is claimed as new. Dr. Fricke 
of Hamburg is looked upon, I believe, as the modern author of this method. A 




few days suffices, frequently, to produce a cure. Compression is applied by means 
of strips of emplast. c. hydrarg, of about half an inch in width. The scrotum is laid 
lold of, and the testicle is forced to the bottom of its coverings. The bandages are 
now applied in circles, the first being placed around the origin of the cord, suffici- 
ently tight to prevent the organ from changing its situation. The process is now 
continued around the testicle, making firm and uniform pressure, avoiding as much 



246 ACUTE INFLAMMATION OF THE TESTICLE. 

as possible any folds in the skin. When the whole organ is in this manner envel- 
oped, another series of strips are applied transversely to the first, to equalize the 
pressure, and give permanency to the whole. [See the cut.'] 

Should the pressure of the plaster occasion much pain, it should be removed until 
the sensibility of the part is diminished. It will usually happen, however, that if the 
plan will succeed at all, the sufferings of the patient immediately abate. The dress- 
ings must not be removed, when they can be borne, until they have become loose by 
the decrease of the testicle. They should then be taken off and renewed. In this 
way, diseased testicle, when the effect of sympathy, is often removed in four or five 
days. 

Should it unfortunately occur that all our efforts to obtain resolution are ineffectual, 
and that the inflammation will proceed to suppuration, then fomentations and poul- 
tices, frequently renewed, and warm as they can be borne with comfort, should be 
kept constantly applied. The moment that fluctuation can be detected, the abscess 
ought to be opened, as the albuginea, being a fibrous structure, is slow in ulcerating, 
and therefore may cause extensive disorganization in the substance of the gland, 
from the confinement of the pus. 

When the inflammation has subsided, there is generally a hardness and thicken- 
ing remaining, together with an enlargement of the epididymis. This condition is 
to be got rid of by stimulating medicines applied to the part. Camphorated mer- 
curial ointment, iodine ointment, the soap liniment or cerateum saponis, are all use- 
ful, and will commonly answer the indication. The emplastrum ammon. cum hy- 
drarg. may be worn on the scrotum with good effect. 

Mercurials internally administered ; the aqua potassae, the iodide of potassium, 
the iodide of mercury, and whatever else can excite the action of the absorbents, are 
all calculated to produce beneficial effects, and I have derived good service from 
each. 

The results of tartrate of antimony, when given after the method of the Italian 
school, in very large doses, have been perfectly astonishing in some kinds of en- 
larged testicle. Dr. Mackintosh relates several instances, when all other remedies 
had failed in chronic enlargement, in which he gave this salt in the undissolved state, 
eight or ten grains at a time, with the effect of causing very rapid absorption. The 
dose seems enormous; I have never tried it, but it is said that the stomach learns, 
after a few doses, to tolerate it, so that no vomiting ensues. 



CHAPTER XIX. 

VENKKKAL INFLAMMATION OF THE TESTICLE. 

TtfERB is one variety of inflamed testicle not usually noticed by authors, and which 
by some is even denied to have an existence, to which, in a few words, I shall pause 
to refer. 

After the syphilitic virus has manifested itself in a constitutional form, there now 
and then may be seen a gradual swelling of one or both testicles, without any appa- 
rent cause of the ordinary kind, and which, therefore, has been attributed by Sir 
Astley Cooper to venereal influence. The reasons for supposing it to be of this 
character, are derived entirely from its history. It is generally accompanied with 
syphilitic sore throat, venereal eruptions, and periosteal inflammation. 

The testicle, and epididymis, under venereal inflammation, become four or five 
times their natural size. The pain which accompanies the disease is not severe, 
but it is increased towards the evening. One testicle being enlarged, the other is 
apt to become affected; but in a majority of cases, the disease commences, proba- 
bly, in both testicles simultaneously. 

The complaint very rarely proceeds to suppuration; but when it does so, it pro- 
duces a granular swelling, as in the chronic abscess. 

■ 

When the venereal poison affects the testicle, it probably in the first place auuvks 
the tunica alhuginca, and thence extends into its interior fibrous, and not into its tu- 
bular part, as this structure most resembles the periosteum in its composition. 

In illustration both of the disease and its treatment, I cannot do better than trans- 
cribe one of Cooper's cases. "A gentleman was the subject of a hydrocele, with 

247 



248 VENEREAL INFLAMMATION OF THE TESTICLE. 

an enlarged testis, and it had been proposed by a surgeon who had attended him, to 
remove the latter, because, in attempting to tap the hydrocele no water had issued, 
and he had therefore concluded the disease to be a solid enlargement of the testicle 
only. I was then requested to see him ; and he mentioned to me that he had some 
enlargement of the tibia, accompanied with nocturnal pains. I desired him to un- 
dress, and upon examining his skin, I discovered a venereal eruption upon the fore 
part of the chest and abdomen. I ordered him to undergo a course of mercury ; 
and as the venereal eruption vanished, the node lessened, the nocturnal pains ceased, 
and the enlargement of the testicle disappeared : the hydrocele was then injected, 
and the patient got perfectly well. He has since married and had several children."* 
There is strong reason for believing in the syphilitic nature of this enlargement, 
and it is desirable, at least, to know whether the opinion be well founded or not, 
that mercury is capable of speedily reducing it when it occurs under the circum- 
stances as above related. In all Cooper's cases, this medicine acted like a specific. 

* Sir A. Cooper on the Testis. 



CHAPTER XX. 



PHYMOSIS AND PARAPHYMOSIS. 



What constitutes phymosis. — What constitutes paraphymosis. — Their causes. — The effects of phy- 
mosis. — Treatment of phymosis. — The soothing method. — Operation by incision. — Operation by 
circumcision. — Treatment of paraphymosis. — Same general indications as in phymosis. — Gentle 
pressure and dexterous manipulation. — Operation with a knife for the reduction. — Subsequent 
treatment. 



When, from any cause, the free extremity of the preputium becomes so narrowed 
that it cannot be retracted upon the glans, but nearly, or entirely conceals the mea- 
tus urinarius, the case is termed phymosis. [See cut.] 




When this same condition partially exists, so that it is possible to pull the pre- 
puce behind the glans, but, when there, it is impossible to get it forward again by 
ordinary means, the case is termed paraphymosis. [Sec cut.] 

249 



250 PHYMOSIS AND PARAPHYMOSIS. 

Gonorrhoea and chancre are the most common causes, but inflammation, however 
excited, may produce such a constitution as to give rise to this accident. Chancre, 
and cicatrices on the prepuce, from their inelasticity, will cause the tightness attend- 




ing irritability of the urethra, particularly in young subjects, and the malformation of 
birth, are other sources of this disease. The contraction is sometimes so great in 
phymosis, that on making water, it is unable to escape as rapidly as it flows from 
the urethra, and swells up the skin into a considerable pouch. It may arrest the 
emission of semen in coition, and thus prevent impregnation. Frequently it is ac- 
companied with a purulent discharge, different kinds of sores, or with warty excres- 
cences on the glans and its covering. In short, from the irritation excited by the 
filth which often accumulates beneath the prepuce of such subjects, almost any va- 
riety of inflammatory affection may be the consequence. 

In the treatment of phymosis, we will frequently succeed by the soothing plan, 
emollients, bathing the part in warm water, and by attempting, gradually and perse- 
veringly, to draw the prepuce back as far as possible. The preputial cavity should 
be washed out from time-to-time with milk and water, or any other bland fluid ; and 
astringent injections, if there be much inflammation, may be thrown in with a syr- 
inge. The diet must be low, exercise avoided, the penis suspended, the bowels 
well moved, and, if the inflammation be very intense, accompanied with fever, blood 
may be drawn from the arm, and leeches applied to the penis. 

When the case is bad, an operation is often required. The two which are most 
approved, I will describe. One is Circumcision, the other is Incision. 

In the latter operation a director is introduced through the orifice of the prepuce, 
and passed down to the reflection along side of the frenum. A sharp pointed, 
curved bistouiy is advanced in the groove until it likewise reaches the reflection. 



PHTMQSIS A\n PARAPHTMOSIS. 853 

Tin* point of the knife is now raised, ami brought through the Bkiilj when B sudden 
stroke backwards Completes the incision. It is but seldom that a ligature is needed 

to arrest hemorrhage. The integuments and the mucosa membrane of the prepuce 

■Onetimes separate, leaving a large raw surface. To prevent tins, a small suture 
should be passed between the membrane and skin oil earh side of the wound. On 
the second or third day the cellular tissue will have become consolidated, so as not 
to allow of retraction, and the suture may be removed. 

For the final few days afterwards, emollient poultices should be applies!. It may 

then l>e necessary for the promotion of the healing of the cut surfaces, to use a 
ily stimulating lotion. CKdema of the prepuce, should it remain, may be got rid 
of by bandaging. 

P>\ this operation all the inconvenience of phymosis is avoided. The skin will 
retract readily behind the glans, and there is not the awkward loose flaps that result 
from making the incision on the top or side. 

The operation by circumcision, as it may be seen in the cut, was first performed 
by Ricord, and is conducted as follows: 




First period. The penis being relaxed, without stretching the skin which forms 
the prepuce, a line is drawn with ink, which marks, in all its circumference, the ob- 
lique direction of the base of the glans, and about an eighth of an inch from it. 

Second period. The prepuce is next drawn forward and fixed between the 
blades of a common dressing forceps, placed directly before the glans, behind the 
inked line, and held by an assistant. 



252 PHYMOSIS AND PARAPHYMOSIS. 

Third period. The portion of the prepuce which projects beyond the forceps, is 
to be held by the operator with his left hand, whilst with his right he makes an in- 
cision with a bistoury, following the line traced with the ink. 

Fourth period. After this section, the mucous lining, which by its anatomical 
disposition does not allow of its being drawn forward, like the skin, remains entire 
and covers the glans; to avoid a secondary phymosis, or paraphymosis, it should be 
immediately divided. This is done by dividing the mucous membrane with a single 
cut with the scissors on the dorsal surface of the glans to its base ; then the flaps 
are removed around to the frenum, and with a single stroke, still holding the two 
flaps together, the froenum is removed with them. The cure is complete in twenty 
or twenty-five days, and no deformity ever remains. 

Should there be much bleeding, the arteries must be tied or twisted. The penis 
must then be constantly covered with cold water to prevent erections and inflamma- 
tion. To avoid erections, the patient should also have camph-or given in the form 
of pills. 

In treating paraphymosis, we have the same general indications to accomplish 
that we have described in phymosis. Gentle pressure of the glans, so that its vol- 
um«>be reduced by squeezing the blood from its vessels, will sometimes enable us 
to slip the foreskin over it. When the soothing plan fails, and serious consecutive 
accidents are impending from strangulation, an operation must be resorted to for re- 
lief. If too long deferred, the glans is apt to mortify, from an arrested circulation. 

The operation consists in making a nick in the contacted edge of the prepuce. 
No extensive cutting is required, provided the knife be applied to the proper spot. 
Having made the incision, by adopting the method above recommended, the reduc- 
tion will easily be effected. In all these cases, there usually is considerable effusion, 
which may be treated by fomentations, rest, and low diet, and in a few days it will 
be dissipated. If the tissues have become adherent to each other through an effu- 
sion of coagulable lymph, the difficulty of relieving the stricture is greatly increased. 



CHAPTER XXI. 



GLEET. 



Its definition. — Commonly succeeds gonorrhoea. — Its infectious character considered. — Proceeds 
from debility. — Various exciting causes. — Its treatment. — If there be general debility of the sys- 
tem, tonics, and remedies for the improvement of the general health. — Astringent injections: the 
manner in which they should be used. — Stimulants and bougies. — Rule for employing thern. — Cau- 
terization. — Glands of Cowper affected. — Treatment. — Bougies and blisters : Cauterization : Coun- 
ter-in itation. — Scrofula an occasional cause: treatment. — Stricture: treatment. — Diseased pros- 
tate : treatment. 



Tins is a disease which is commonly the sequel of gonorrhoea, and indicates a 
chronic inflammation of the mucous membrane of the urethra. It is characterized 
by a thin, watery discharge, having the consistency and appearance of mucus, and 
is, no doubt, a true secretion of the mucous follicles and glands that exist in this 
part. j 

It succeeds, usually, a thick, purulent secretion of matter, which accompanies an 
acute inflammation, and when it follows gonorrhoea, it may be said that no small 
difficulty exists in determining whether it is infectious or otherwise. On this sub- 
ject the opinion of medical men vary, owing, no doubt, to the want of precise knowl- 
edge as to what constitutes the affection under consideration. Where the one ter- 
minates and the other commences, is not always easy to decide. Of this we can 
only judge from the history of the case, and the appearance of the discharge. What 

253 



254 GLEET. 

one medical man may term gleet, another may believe to be gonorrhoea; and this 
want of accuracy springs, I apprehend, from the difference in the views entertained 
by various persons respecting the time when the matter has ceased to be infectious. 
Nearly all unite in saying that gleet is incapable of reproducing in another individual 
the symptoms of gonorrhoea. When the discharge has become almost or quite col- 
orless, and of a gummy consistency, like mucus, it may be believed that it will not 
communicate infection. There are those who suppose that, long before this period, 
it is often quite harmless. 

Gleet may likewise arise from any other cause that, in the first instance, can awaken 
an inflammation, or, perhaps, even an irritation of the lining membrane of the urethra. 
The pathological condition of this membrane, when such a discharge is present, I 
conceive to be, commonly, one in which there exists a decided degree of debility in 
the organs secreting the mucous fluid. This view was denied by Hunter, who 
supposed that in all cases when there was an increased secretion in a part, there 
must also be increased functional action. At first sight, this proposition, it must be 
acknowledged, strikes one as being very plausible* and in correspondence with what 
would naturally be expected. But, 1 imagine, there is an absolute deficiency of tone 
in the membrane, just as may be observed in some forms of dropsical complaints, 
when the tissue no longer possesses the power of resisting the force with which the 
circulation is impelled, and its serous parts escape into the cellular substance, cavi- 
ties, or upon the mucous surfaces. It is not essential to the force of this opinion, 
that the effusion shall, in all the various cases, be physically identical. There are 
many circumstances to modify it; and it must be believed that difference in the 
exhaling surface or organ, may, at least, have some effect in altering its properties. 
The glands secreting mucus, I suppose, in consequence of long protracted, or se- 
vere disease, become much debilitated, and sometimes organically altered. The 
blood is still supplied to them in quantities as great as when in health, but they have 
lost their capacity of elaborating from it that fluid, which, in a normal state, it is their 
function to produce. The watery elements of the blood, being thinnest, readily find 
their way through the intestinal substance of the gland, mingle with what may be 
considered as imperfectly secreted mucus, and thus, by the combination of these two 
elements, a gleety discharge ensues. 

There are certain facts, which, if they do not furnish direct evidence in support 
of this view, at least veiy strongly corroborate it. The amount of secretion does not 



GLEET. 865 

in to l>«ar u direct proportion to the excitement of a part. If the inflammation 
of the mucous membrane be intense, it Lb well known that the mucous discharge is 
sometimes wholl) arrested. This is often observed iu the lungs as well as in the 
urethra, and the most certain Bign of a mitigation oi* the affection, is an increased 

expectoration. Our remedies, therefore, when such an accident occurs, an' selected 

with an especial view of soliciting such a discharge; and it so happens, that they 
are those which have most influence in Biibduing high inflammatory action. 

It will be understood, from what I have said, that gleet is not always dependent 
upon a venereal cause. A certain condition of the mucous membrane, whatever be 
the primary affection, is all that is necessary to constitute the disease. We there- 
fore have gleety weepings, resulting from intemperance, gravel, calculi, venereal ex- 
D sses, masturbation, acrid urine, ulceration, cold, stricture, or any other cause of 
inflammation, which may degenerate into the chronic state. 

I have enumerated stricture among the causes of gleet, but I am by no means so 
willing to acknowledge it as so common a one as manv authors assert. The two 
pathological states very often exist, certainly, but I do not see why it would not, in 
most instances, be quite as logical to say that stricture is the consequence of the 
gleety condition, as to reverse this order of cause and effect. Looking at the his- 
tory of the two affections, it will usually be found that gleet has existed long before 
stricture makes its appearance in the urethra. In ninety-nine out of a hundred in- 
stances, such is the fact. The symptoms of stricture are always very slow in devel- 
oping themselves; and months, or even many years elapse before obstructions in the 
canal present themselves. Not so with gleet. This is a direct and early sequel of 
acute inflammation ; and, when long continued, there is, ultimately, the new symp- 
tom of stricture. 

The fact seems tr be, that both stricture and gleet are dependent upon the same 
morbid cause — a chronic inflammation of the urethra; but gleet is the soonest and 
the most constantly developed. When stricture is finally formed, it becomes, I 
know, a fresh source of irritation of the mucous membrane situated between it and 
the bladder. A new series of pathological actions and reactions will now probably 
take place, — the stricture grow more formidable, and the gleety discharge be in- 
creased. 

I do not mean to assert that, in no instance, can there be a gleet without inflam- 
mation. Such forms of it do, perhaps, occasionally present themselves. With no 



56 GLEET. 

previous inflammation, this kind of discharge may, possibly, arise ; but! can truly 
say that I have never yet met with a well established case. I am inclined to make 
this admission, not because I have had any direct proof to satisfy me, nor even be- 
cause others have argued for it, but because there are certain analogical reasons for 
adopting such a conclusion. Leucorrhoea in women is a discharge that may be 
considered as often strongly resembling that of gleet. It comes on without any ap- 
parent inflammation, merely from relaxation of the membrane ; is long continued, 
and frequently very difficult to cure. It is from such facts that I conclude it to be 
possible to have gleet as the result of simple debility. 

Thus much upon the various causes of gleet; but that which most interests us is 
the species of gleet which is the consequent of gonorrhoea, both from the reason that 
it more properly belongs to the diseases of which this book especially treats, and 
also because it is much the most frequent, most obstinate, and may, sometimes, com- 
municate a venereal disease. 

If the virus of gonorrhoea be exhausted, sexual intercourse can be indulged with- 
out danger of infection ; but as there is much uncertainty in deciding when this con- 
dition is reached, it should always be deemed hazardous to make experiments. The 
best plan, obviously, is to get rid of the discharge, and avoid risks. It is sufficient 
to know that unpleasant results may sometimes ensue from our imperfect knowledge 
of what is and what is not contagious, to make us very cautious in expressing to 
patients an opinion respecting the infectious character of the running. 

TREATMENT. 

There is scarcely any disease that we are called upon to treat, which requires 
more judgment, patience, and a more varied application of the resources of the heal- 
ing art. He who expects to remove this affection by any particular remedy, under 
the delusion that the proximate cause is always precisely the same, will, in practice, 
find himself wofully disappointed. 

Should gleet be accompanied with general debility, general tonics must, in the first 
instance, be resorted to, and every condition removed which can keep down the vital 
powers. The secretions of the liver and bowels must be duly regulated ; the stom- 
ach must have no duties imposed upon it which it cannot readily perform; while the 
food should be nourishing, without being highly stimulating. The general tonics 



GLEET. 2- r >7 

embrace a wide scope. It" the patient look exsangneous, some of the ferruginous 
class are to be preferred, or they may be given, combined with a bitter vegetable. 
I prefer in these cases, the tincture of the muriate* of iron; and there are many 
instances in which it may be administered very advantageously with the tincture of 

Cantharides. If iron be contra-indicated, the compound infusion of gentian, with 
the compound tincture of cardamons, will often prove of the most decided benefit. 
These remedies, however, may be varied according to circumstances ; and, should 
one fail, others may successively be tried. But while we are pursuing the constitu- 
tional treatment, we will find, often, that, although the patient is improving in general 
health, the local disease seems to be growing worse. Greater quantities of blood 
are conveyed to the debilitated tissue, and an increased discharge occurs some- 
times, perhaps, by re-exciting a higher grade of inflammation, but, usually, because 
the atonic condition of the membrane cannot resist the pressure of the blood, the 
watery elements of which are exhaled somewhat in the same manner as in dropsies 
of other parts. Attention, therefore, must constantly be directed to the expectation 
of this occurrence ; and it will, generally, be advisable to use astringent injections 
in conjunction with the constitutional means. Solutions of sulphate of copper, 
sulphate of zinc, or sulphate of alum, are very serviceable. In short, it is impos- 
sible to particularize any single article, or formula as superior to others, for I have 
frequently seen one answer with this patient while with that it was quite without 
effect. 

The majority of cases require no general treatment whatever, and local remedies 
only are indicated. Such astringents as those above mentioned, may be first used, 
and very often they will prove to be sufficient for a cure. There are some others, 
which, these failing, may be resorted to, and for which I shall give formulae at the 
close of the book. They may be used without any danger of unpleasant conse- 
quences, and therefore, should have a fair and full trial. There is one fact in using 
injections of this nature which I wish particularly to impress upon the reader. It 
happens, constantly, that medical men are disappointed in using injections from the 
very inefficient way in which they are employed. It is not enough to throw into the 
urethra an ordinary solution but three or four times a day, or to inject it and permit 
it to escape again as soon as the instrument is removed from the orifice of the canal. 
It ought to be repeated every hour or two, and at each time, it should be confined 
in the urethra for two or three minutes, or until there is a slight sensation of smart- 



258 GLEET. 

ing. This gives the medicament an opportunity of making an impression, and when 
this is again and again renewed, so that its influence is all the time maintained, we 
shall have reason many times to feel delighted with the effects, while, by the usual 
trifling practice, we should have met with nothing but disappointment. From being 
improperly or only half administered, the best means are too often unjustly con- 
demned, the fault lying either with the practitioner or the patient, and not with the 
remedy. 

Having given the astringents a thorough test without any beneficial result, it 
would, of course, be perfectly idle to persist any longer in their use. They should 
now be laid aside, and a different plan adopted. There being no pain, or but very 
little, we are at liberty to conclude that the stimulating treatment will answer better. 
Here again we have a great choice of means — acrid solutions as injections ; 
balsam, cubebs, turp'entine, etc. given internally, and bougies. The internal and 
local means may be simultaneously employed, and probably with better effect than 
if either be used alone. Whichever may be had recourse to, it should most com- 
monly be a principle in the treatment to avoid using them so strong as to excite any 
considerable degree of inflammation. A moderate sense of heat in the urethra is 
quite sufficient to begin with : if the milder means be ascertained, upon trial, to be 
inadequate, the irritation may be increased by making them stronger ; or, if the 
bougie be selected, by adopting such methods as may be necessary to give it greater 
power. Some of those which answer as astringents, if the strength be increased, 
will answer very well as stimulants. But that which I prefer above all others, is a 
solution of nitrate of silver. I commonly begin with it in the proportion of one grain 
to the ounce, and either make it stronger or weaker, as circumstances may seem to 
require. There are cases in which. I have even ventured to use it in the proportion 
of two hundred grains to the ounce. It is obvious, that, in this instance, the effects 
are no longer those of. a stimulant, but of an escharotic. On this principle I so em- 
ployed it, and I am happy to add, with the most complete success. I do not, how- 
ever, recommend this strength to others, because, if cauterization be desirable, it is 
fur better to employ the caustique-holder to attain the end — a method that is neater, 
more surgical, and more certain, without being liable to the objection of cauterizing 
parts that do not need it. The cauterization should be very slight when it is done 
at all, and therefore ought to be performed very rapidly. It but seldom is the case, 
however, that it is needed. The end we have in view, can generally be reached by 



QL8ET. 869 

■imptcr, and what are thought to be milder measures. The following formula an 
uIsd \ci\ useful, ami may be tried in Bach cases : 

i;. Liquor! 9 Cupri Amraoniati, M- \\. 
Aquse Rosae, 5- iv. M. Or the 

l! . 11 ydrarg. Bichlorid. grs. ij. 

A 1 1 1 i.i- Destillaii, E. i\ • 

Inordinary gleets, without complications, this treatment will always bring about a cnre. 

We proceed now to notice another variety mach more difficult to manage. If 
the original inflammation has extended beyond the bulb of the urethra, and per- 
I for a considerable length of time, the glands of Cowper, and their excretory 
ducts leading to the urinary canal, become in like manner diseased, and render the 
affection far more perplexing to treat. We may now use astringents and stimulants 
without any further effect than to reduce the discharge which proceeds from the 
small superficial glands of the membrane. The large and deep-seated are not 
readied 1>\ the remedies, and no impression, therefore, is made upon them. When 
we find the case to be of particular obstinacy, we may conjecture that we have one 
of this variety. If, in addition, there be considerable tenderness in the perineeum, 
and if the matter appears to come from a distance from the meatus, which may be 
ascertained by judiciously directed pressure along the course of the urethra, we will 
seldom be wrong in assuming that the glands of Cowper are implicated. 

Injections must now be abandoned. Bougies, and blisters applied to the perineeum, 
are the remedies to be adopted. The bougies should be as large as the capacity of 
the urethra will easily admit, so that they excite a moderate degree of inflammation, 
without doing mischief. Small ones, unless there be stricture to overcome, glide 
along too readily to produce any salutary results, and we had as well do nothing as 
such instruments. In a few days we will generally witness the good effects of 
this method ; but we are not to suspend this proceeding so soon as the gleet has 
■bated. The relief will otherwise be only transient. The cure has now merely 
begun, but is very far from being perfected. The bougies should be persisted in 
for many weeks, and then, if the discharge has ceased, we may venture to feel 
assured that the disease will not return. 

It is advisable during the progress of this treatment, occasionally to lay the bou- 
gies aside for a few days at a time, in order to ascertain, if the discharge continues, 



\ 



260 GLEET. 

whether it is caused by the original irritation and debility, or whether it may not be 
caused by the irritation which the bougie has excited in the urethra. It is easy to 
see the policy of this plan; for our remedy may be keeping up the running, which 
we are in vain trying to stop. If the result of the experiment be favorable, then are 
our hopes encouraged, and we may properly persevere. But if otherwise, and the 
instrument has been employed long enough to give salutary fruits, and yet the dis- 
charge is unchecked, we ought to relinquish this simple treatment. It is now time 
to try the effects of cauterization. The porte-caustique, armed with nitrate of silver, 
should be freely and boldly introduced to the part which is the seat of the disease, 
and the operation repeated according to circumstances, once or twice a week. By 
this course, I have often succeeded with the most stubborn cases, when every thing 
else had utterly failed. 

When the bougie and cautery fail, we may try the virtue of blistering on the peri- 
nseum. This is a practice I am always reluctant to resort to, as it is particularly an- 
noying to the patient, on account of the inconvenience experienced in dressing the 
blistered surface, in walking about, and on account of the pain it inflicts. A single 
vesication can scarcely be expected to do much good. It must be repeated as soon 
as the first blister has healed. By thus continuing the blistering process for some 
time, we will occasionally have the satisfaction of seeing it effectual. Or, after having 
opened an external discharge, we may convert it into an issue by dressing a small 
spot with epispastic ointment. Perhaps this latter method is to be preferred to the 
other. 

There are other ways of making counter-irritation, which I need not speak of, as 
they are not likely to be of more service than those above indicated. Every medi- 
cal man has his own preferences. As I consider that it is the fact of derivative ac- 
tion, and not the mode of exciting it, which is essential, I forbear to spend time in 
dwelling longer upon a mere matter of fancy. 

It sometimes happens that the gleety discharge is continued in consequence of a 
vitiated condition of the constitution. Scrofulous patients can scarcely be hoped to 
be cured by merely local means. When we have such persons to deal with, sound 
judgment suggests the internal exhibition of medicines, which experience has proved 
useful in the general affection. 

If we find enlarged lymphatic glands about the neck, and the complexion of the 
patient present the hue which is the sign of a scrofulous constitution, then the thera- 



QLBET. 201 

pentical indications arc clearly in favor of some ofUM nariom preparations of iodine, 
commonl) combined with a ionic. It will nearly always be found, unless there is 
i special contra indication, thai tin 1 iodide of iron will prove superior to everything 
else. Sen bathing may also be resorted to; and this is a remedy, which, when it 
can be conveniently used, is of very great value, and should never be neglected. 
Sponging the body with salt and water every day, beginning with it moderately 
warm, and reducing the temperature ns the body becomes accustomed to the cold 
shock, is a good substitute for sea-water. The clothing should be ample, to pre- 
serve 1 the surface from cold, and sodden atmospheric changes. In fine, everything 
must be adopted, both as respects medicines and regimen, which can invigorate the 
powers of the system, and counteract the morbid effects of a feeble performance of 
the functions of nutrition. 

W hen the discharge is maintained by stricture, the remedy, of course, is that 
which will remove the obstruction. Here our great resource is the bougie. Such 
cases I always cure readily by using this instrument. I shall say no more touching 
this cause than to advise, in all instances, when a patient laboring under gleet pre- 
sents himself to us for assistance, to pass the bougie at once with the view of deter- 
mining at the outset whether a stricture exists or not. If a coarction be discovered, 
it is judicious, in the first instance, to remove it, by which means we may, perhaps, 
immediately relieve the patient, or, at least, we shall extricate ourselves from a vexa- 
tious complication. 

A chronic running from the urethra may be kept up by a diseased state of the 
prostate gland. It is highly important to diagnose this condition, as the ordinary 
remedies for gleet in such cases are actually worse than useless. 

There may be merely a disease of the urethra of this part, which will manifest it- 
self more by a frequent desire to make water than by pain. When such is the case, 
the bougie will probably be found a sufficient remedy, and I believe that cubebs, act- 
ing as a gentle stimulant, will often do much good. 

When, however, the substance of the gland is affected, the cure will be more dif- 
ficult- If the patient be young, we may anticipate that, ultimately, he will be re- 
stored to health. Abscesses may form, which, if necessary, must be opened. Opi- 
ates will frequently be required; but it happens too often that our whole treatment 
can bo little better than temporizing. The strength should be maintained by tonics, 
of which the sulphate of quinine, or iron is the best. In some instances, particularly 



262 GLEET. 

if scrofulous symptoms present themselves in other parts, the iodide of potassium will 
prove a very valuable medicine. By adopting such treatment, and whatever else 
the varying symptoms seem to demand, we shall usually succeed in getting the pa- 
tient through his sufferings, and restore him once more to sound health and strength. 
In those gleets which may be induced by the occasional causes that I have 
named at the beginning of this chapter, we cannot hope to afford the patient much 
service, so long as the first cause continues. Thusj if an irritation of the urethra 
succeeds to gravel, or acrid urine, &c, our first care is to correct that state of the 
system which favors such conditions of this excretion. The sabulous deposit must 
be prevented by those means that the nature of the earthy matter suggests ; and the 
irritating urine should be corrected by the internal administration of such substances 
as will act chemically upon its constituents, and restore it to the healthy state. This 
being accomplished, we shall have no obstacle to a radical cure ; to bring about 
which, it is advisable to proceed according to some of the methods already detailed 
in the previous pages. 



CHAPTER XXII. 



STRICTURE OF THE URETHRA. 



Definition of Stricture. — Its cause. — Plate of urethra. — Dimensions of urethra. — Varieties of stric- 
ture. — Their symptoms. — The opinions of Hunter and Home controverted. — The seat of stric- 
ture. — Retention of urine. — Some of the consequences of stricture. — Diagnosis. — Mode of intro- 
ducing catheters. 



The affection of which I have now to treat, is another link in the chain of morbid 
phenomena proceeding, usually, from inflammation of the urinary canal. Stricture 
is commonly a sequel of gonorrhoea. Some authors allege that it is so as often as 
ninety-eight out of a hundred cases. Without giving any decided opinion upon this 
question, I cannot doubt that such statements, although exaggerated, have a very 
strong show of truth. In an immense majority of instances, stricture has a venereal 
origin. 

Stricture, in a general sense, is either a partial or complete closure of any passage 
of the body, and occurs in the oesophagus, the windpipe, the intestines, in the 
urethra, <fcc. Fortunately, it is a very rare accident in any of the first named pas- 
sages. In those situations, though not absolutely fatal, it is always attended with 
the greatest danger. In the urinary canal, it is constantly met with, and, without 
often putting life in jeopardy, when surgical assistance can be promptly obtained, it 
is usually productive of much distress and inconvenience. 

263 



264 



STRICTURE IN THE URETHRA. 



The urethra is intended for the discharge of the urine, semen, prostatic liquor, and 
the fluid secreted by the glands of Cowper. It passes above the lower extremity of 
the rectum, and immediately beneath the symphisis pubis. 




EXPLANATION OF PLATE. 



This cut represents a cast of a strictured urethra, taken by Home, which was made by injecting the 
canal with wax, and afterwards cutting open the urethra and removing the model, that formed a bougie 
of the exact size of the canal, and was impressed with all its natural irregularities. 

The drawing is i*educed to one half the dimensions of the original. The cast was taken from the 
urethra of a man thirty years of age. 

A. The bladder. B. The neck of the bladder. C. The canal which passes over the prostate gland, 
and extends from B. to D. F. The membranous portion of the urethra. Gr. A natural reduction of 
the calibre of the canal, directly behind the bulb ; but in this case it is somewhat smaller than usual, in 
consequence of a stricture which had formed here. This is the situation in which stricture is most 
commonly found, and which, more than any other part, is subject to obstructions of this nature. H. 
The bulb of the urethra. I. A portion of the canal slightly narrower than the rest. K. The fossa 
navicularis, a natural enlargement, about three-fourths of an inch from the orifice of the urethra. 



The length of the canal has been variously estimated by different anatomists, 
some having put it down as being not more than seven and a half inches, while 
others have exaggerated it to twelve. In order to determine this point, M. Whately 
measured the urethra of forty-eight subjects, whom he divided into three classes, 
viz: — the first of high, the second of middle, and the third of low stature. In 
each of these classes, however, there were some differences in size, and in many of 



STRICTURE in THE mjktmka. 265 

them eooeiderable variations in Ihe length of the projecting parts of the penis. The 

following is the result of his inrasiirenients : 



High Stature. 



In 1 

s 
5 
8 . 

Middle Stature. 
In 8 

1 

7 

2 . 

7 

2 . 

1 
Zwr Stature. 

1 

2 

4 . 

2 



length of 


Urcth ra 


IN( II 




10 




9 


6 


9 




8 


6 


9 


6 


9 


3 


9 




8 


9 


8 


6 


8 


3 


8 




9 


3 


9 




8 


6 


8 


3 



These investigations show the medium length of the canal to be eight inches and 
eleven lines. My own experiments, which have been repeatedly made with the 
same view, confirm the general accuracy of Mr. Whately's table. 

Lisfranc found, in some of the subjects which he examined, that the urethra meas- 
ured eleven inches ; but it is obvious that in this statement there is great probability 
of error. It is, indeed, declared by some authors of eminence, that it never attains 
such a length in Europeans, but that in the negro, it may, possibly, sometimes be 
the case, as their genital organs, both in the male and the female, are more largely 
developed. 

The diameter of the urethra, is, perhaps, of more practical importance to be ac- 
curately known, than the length ; for, unless we have a correct knowledge of the 



266 STRICTURE IN THE URETHRA. 

strictured canal when in the healthy state, we can scarcely hope to meet with com- 
plete success in restoring it to the natural size. 

The only observations on this subject, so far as 1 know, which have been pub- 
lished to the world, are those of Home and Lisfranc. Sir Everard Home injected 
the urethra, as described in the preceding cut, of two persons, one of whom was^)e- 
tween seventy and eighty, aud the other thirty years of age. In both of them the 
penis was of small size, and the external orifice, at the glans, unusually small in the 
collapsed state. The following is a view of the diameters : 



At three-quarters of an inch from the external orifice, 

At four and a half inches from the external orifice, . 

At seven inches from the external orifice, (at the bulb,) 

At seven and a half inches from the orifice, at the commence- 
ment of the membranous portion, (where in the younger 
subject, there was a stricture,) . . . . 

At eight and a quarter inches from the orifice, near the termina- 
tion of the membranous part, .... 

At eight and one half inches from the orifice, where the mem- 
branous part terminates, and the prostate gland begins, . 

At eight and three-quarters inches from the orifice, in the 
middle of the prostate gland, .... 

At nine inches from the orifice, the neck of the bladder, 



It ought to be borne in mind, that the dimensions as given above, are those that 
the urethra will acquire when fully expanded, and much beyond the size on ordinary 
occasions. 

I know of no reason why stricture of the urethra should ensue more frequently 
from gonorrhoea, than from any other species inflammation. No reason, surely, 
can be found in the specific nature of the virus ; and, whatever opinions others 
may entertain, it is mine, that specific disease exerts no specific effect — the con- 
striction being wholly the consequence of an ordinary inflammation or irritation. In 



AGE 80. 


AGE 30 


of an. 


Inch. 


9 
2 


7 
2 o" 


7 
~2 0" 


7 
2 0~ 


JL-2 

2 


2 


7 
2 


_1_ 
2 


9 
2 


7 
2 


7 
2 


6 
2 


1 1 

2 


1 

2 


9 
2 


8 
2 



si-kicti'KI-: ()K THE URETHRA. 



867 



a given DOmbtr ot* cases, I believe, however, tlml gOMMTflMM will, more frequently, 

p ro d u ce stricture than inflammations depending upon other causes. This result I 

explain hv the fart that the iiillamination of gDQOTrhCBa is usually much more pro- 
tracted than any other, and too often ends in the chronic kind, which may continue 
tor manv months, or even vears, during all of which period, tin; mucous membrane 
ot* the urethra . is becoming more and more diseased, and is gradually laying the 
foundation for a permanent stricture. 





j 
i 




EXPLANATION OF PLATES 



These cuts, representing the appearances strictures present, show small bougies introduced up to 
the obstruction, and doubled back upon themselves, as will happen when the instrument fails to find the 
passage, and is still pressed onward. 






I have said that the cause of stricture is usually inflammation, and that gon- 
orrhoea is the most frequent exciting cause. From what I have also said, it will be 
understood that whatever else can arouse inflammation, may, in like manner, be an 
exciting cause. Thus calculi, gravel, venereal excesses, masturbation, cold, acird 
urine, etc., may be said to be, occasionally, a cause of stricture, because they all will 
produce urethral inflammation. 

Strictures have usually been divided into three varieties — the Permanent, the 
Spasmodic, and these two, in combination, the third variety. 



268 



STRICTURE OF THE URETHRA. 



The first of these varieties is organic. It arises from an actual change 
in the substance of the urethra. This may be subdivided into several 
others, each one depending upon the pathological changes which the tissues 
have undergone. So long as the inflammation be confined to the mucous 
membrane, there will probably be merely a thickening, or a kind of hyper- 
trophy, which may or may not be accompanied with fleshy vegetations, or 
fungous granulations. This condition may cause a stricture of Considerable 
extent, reaching, sometimes, for an inch or two along the canal ; and, indeed, 
I have met with cases in which there was a reduction in its calibre through- 
out its whole length. This thickening most commonly takes place only on 
side of the conduit ; and, in practice, it is a matter of some moment to know 
which side may be thus effected, as such knowledge diminishes the difficulty 
of introducing, readily, the bougie. This may be accurately ascertained Dy 
means of the instrument seen in the margin.* 

If the inflammation have extended beyond the tissue originally involved, 
and established itself in the subjacent ones, the diameter of the urethra will be 
reduced by an effusion of coagulable lymph in the corpus spongiosum, which, 
becoming there organized into a fibrous structure very dense and inelastic, 
presents an obstacle to the passage of urine more obstinate than that of which 
I have already spoken. Strictures of this description are designated the in- 
durated, on account of their great hardness. There are other strictures 
resembling this variety in their nature, but they present themselves in a 
somewhat different manner. The lymph, instead of being poured into the 
cellular tissue, is effused into the urethra through an opening made in the 
mucous membrane by ulceration. Here it becomes concreted and organi- 
EnJpr^te. zed. At other times it is effused upon a limited surface of the mucous 
membrane, forming a kind of bridle — a mere curtain — or it may create an obstruc- 
tion precisely as if a thread were drawn tightly around the penis. Sometimes, though 
seldom, there is an extensive effusion of lymph over a great surface of the canal, 



* The porte empreinte, or model sound, is formed by taking a hollow bougie, through which is passed 
a strand of cotton thread, leaving about half an inch of it projecting beyond the inner extremity of the 
bougie. This is dipped into a composition made of equal parts of bees-wax, diachylon, and shoe- 
maker's wax, and allowed to cool. It is then rolled between two pieces of wood until it is made quite 
round, smooth, and of the diameter of the other portions of the bougie. 



^^^" 



STRICTURE OF THE I RETHRA. 



269 



which becomes, at length, a false membrane, such as may he observed in the larynx 
ami trachea of children severely allected with croii|). I iniiv here mention that the 
lened base of an old chancre, is another occasional cause ol* stricture. It is un- 
necessary to refer to any Other of the causes, as they are rather curious than impor- 
tant m practice. 




EXPLANATION OF PLATE. 

Tins plate represents different forms or strictures, with impressions that have been taken by the 
model bougie, (porte empreinte). Figures 1, 2, 3, 4, show urethras with the passages nearly closed. 
Figurii I, 6, 7, s , show the impressions of them which have been made wilh the porte empreinte. 
Those without numbers are impressions of the like kind, which fuither exhibit the great variety of 
shapes that strictures assume. 



The second variety — the Spasmodic — is one, the existence of which is wholly 
denied by some surgeons of eminence ; but there are such good reasons for believ- 
ing that strictures of this nature not unfrequently occur that, for my part, I no more 
doubt the spasmodic, than I do the permanent kind. 

It is a common thing to see patients suddenly attacked with a retention of urine. 
After a free indulgence in the pleasures of the table, and partaking liberally of 
acid wines, or punch, persons often find, when they attempt to urinate, that not a 
drop will pass. The same sudden obstruction may take place from cold, from the 
application of blisters, as related by Home, who ascertained by introducing instru- 



270 STRICTURE IN THE URETHRA. 

monts, that it was not mere strangury from irritation at the neck of the bladder, but 
an actual spasm just behind the bulb of the urethra. 

Whenever a difficulty happens in a sudden manner, it must be from spasm, what- 
ever may be the cause inducing it, and this may be any thing which will excite 
irritation. 

The remedies to which we resort for relieving such cases, also prove, in an indi- 
rect way, the nature of the affection. Opiates, the warm bath, hot fomentations to 
the perinseum, and, in short, every remedy, internal and. external, which are known 
to possess an anti-spasmodic effect, are employed with benefit. Were the stricture 
of the permanent kind, such results could not be expected, or, if they were, there 
would only be disappointment. 

Facts like these convince me that the idea of spasmodic stricture is well-founded. 
I do not, however, believe that the urethra is muscular, as was conjectured by John 
Hunter, Sir Everard Home, and other writers who lived before them. It is, I ima- 
gine, possessed of certain contractile properties throughout its whole extent ; and it 
is its capacity for dilitation which gives rise to the phenomena that have been mis- 
taken for muscular actions. The accelerator u rinse muscles, and the muscle of 
Wilson, as it has been called, which surround the membranous part of the urethra, 
are the true agents of spasmodic stricture. It is at this point that permanent ob- 
structions most frequently form : therefore it is probable that the irritation and in- 
flammation producing the one may also be the cause of the other. Spasm is the 
consequence of irritation, and when this is long continued, structural changes occur 
that form strictures of the "permanent kind. 

There is no difficulty in perceiving how these two kinds may be united, as they 
both are seen succeeding the same abnormal conditions. If irritation, transiently 
excited, can produce spasm, when longer continued there is no reason why it may 
not manifest the same effects. But there is, besides, every reason for believing that 
when a permanent stricture already occupies the canal, a more exalted grade of irri- 
tation may suddenly be induced, by accidental circumstances, just as might happen 
if no permanent stricture existed. The two causes concurring, an obstruction of the 
mixed kind will require the surgeon's aid. 

This, I apprehend, is the variety of stricture of most usual occurrence ; and as in 
retentions of urine a permanent stricture is commonly met with, the notion has been 
taken up that all strictures are, essentially, of this nature. 



STRICTURE OF THE I RETHRA. i^7 L 

Tin Si vi of Strii ni:r. — There is a cnriuns fact connected with the situation of 
stricture, which, l>v some surgeons, is considered almost unaccountable. It does 
not. it is true, always appear at the same place ; hut, in .'i large majority of instances, 
it is found immediately behind the bulb, and anterior to the membranous portion of 

the urethra. There mav lie strictures in other parts of the canal, but if there he, 
we are licarlj certain of finding one here also. By some, this has been referred to 
a predisposition in this spot to inflammatory action. The cause is to bo found in 
the triangular I gament of the pcrineeum, and in the arrangement of the muscles of 
the urethra, which act on this portion. To my mind, the circumstance is in this 
way satisfactorily explained. Here the urine is liable to be checked by a muscular 
contraction ; and when the contraction occurs frequently, or is continued for a con- 
siderable length of time, a kind of strangulation is produced, or, at least, increased 
hyperemia and inflammation. Let mc demonstrate my view by a synthetical pro- 
Suppose we have a case of gonorrhoea, the inflammation commencing at the 
meat i s. It extends gradually backwards until it reaches the triangular ligament. 
The muscles now sympathize, and contract strongly, producing, perhaps, a difficulty 
in emptying the bladder. As yet, however, there is nothing worse than a spasmodic 
Stricture. This morbid action, being long continued, the irritation in this place being 
kept up, after it is subJned in other parts, by the muscular movements and the 
retention here of a small quantity of urine, which becomes anew source of irritation, 
there is, ultimately, a transformation of the tissue, and a stricture of the permanent 
kind is established. 

There is no part of the urethra exempt from permanent stricture, but it is a very 
rare thing to find it in the prostatic portion. 

The Symptoms of Stricture. — Wherever be the seat, or whatever the variety 
of stricture, its effect is, under all circumstances, to produce a retention of urine, 
which is more or less perfect, according to the degree of the obstruction. 

The advance of stricture is generally slow, and it is but seldom seen in persons 
under the age of puberty ; after this period, until the age of forty-five, it is common ; 
beyond this time of life it is less frequent, though it still is not of rare occurrence. 

Should a man who has not got beyond the middle period, consult a surgeon, com- 
plaining of a difficulty in making water, it is probable that he is laboring under 
stricture. The same conclusion may be drawn from the symptoms of an old man 
provided he had experienced some difficulty for several previous years. But should 



272 STRICTURE OF THE URETHRA. 

he declare that the obstruction was only of recent occurrence, then there is probably 
an obstruction from an enlarged prostate gland. 

When the membranous portion of the canal is the seat of stricture, the patient 
may have complete retention much earlier than if it is forming upon any other point, 
for the reasons that I have submitted in my remarks upon the seat of the disease. At 
its origin, the disease, when situated here, is almost wholly spasmodic. The reten- 
tion comes on suddenly, and is the consequence of irregularity in eating, or a de- 
bauch, or, indeed, whatever can arouse an inordinate degree of irritation in the 
urethra. 

The first symptoms of permanent stricture make their appearance so insidiously 
as scarcely to attract any attention. The urine flows in a smaller stream, which is 
twisted, or forked. The water is passed slower, but the patient experiences no in- 
convenience beyond a slight scalding during the moments of its evacuation, with an 
itching or uneasiness along the course of the canal, and a sense of .heaviness at the 
perineeum. Gradually the stream becomes more slender and feeble, a longer time 
is required to make water, and less is passed at once ; a desire is more frequently 
felt, so that the patient is obliged to rise several times during the night. At length 
it is impossible to void the urine without considerable straining and long continued 
efforts, which are accompanied with much pain and swelling of the penis. When the 
patient has discharged as much as possible at one attempt, by renewing the effort it 
will be discovered that he is capable of voiding more, and, therefore, that in the first 
instance the bladder had not been completely emptied. Having retained his Avater 
for some time, he experiences a sense -of weight in the groins, and pain above the 
symphisis pubis ; and upon making pressure over the latter spot, a severe pain will 
be felt, with a strong inclination to urinate. This proceeds from a greatly distended 
bladder. 

The difficulty of making water continues slowly to increase ; the stream becomes 
more thread-like, and at length may issue with so little force that it can no longer 
project itself in a jet, but falls directly from the orifice of the urethra between the 
legs. This last symptom takes place, it is believed by Lallemand, in consequence 
of there being several strictures in the canal instead of one, and with this opinion I 
am inclined to accord. 

There are patients in whom the symptoms indicate a yet more wretched condi- 
tion. The water only escapes the guttatim, and the quantity made at each attempt 



STRICTURE OP THH ORBTHRA. 273 

is wry small. They are tormented with nn incessant uneasiness and desire to re- 
lieve the bladder, and nearly half their time is consumed in this employment. The 

patient is reduced i<> BUCh a strait that he is obliged to place himself in the attitude 
uned at stool, that he may the better make the necessary expulsive efforts; find 
it sometimes happens thai the contents of the lower bowel are discharged involunta- 
rily at the same instant. This violent straining occasionally causes a hernia, increas- 
ing thus the maladies of the patient, and compelling him to harness himself with a 
truss. The sphincter ani muscle is at length relaxed by the constant pressure upon 
it ; the rectum descends, and constitutes prolapsus ; bleeding piles are complicated 
with it ; the intestine is at last, perhaps, sympathetically irritated, and a troublesome 
diarrhoea is joined to all the other miseries that nearly overwhelm the sufferer. 

If the patient be not relieved, his sufferings go on increasing. The constant full- 
ness of the bladder, and of that part of the urethra behind the stricture, end in 
chronic inflammation. This reacts on the disease in front ; the prostatic gland be- 
comes diseased and swollen ; the inflammation extends along the ejaculatory ducts 
to the vesiculae seminales, causing frequent involuntary seminal discharges ; and it is 
propagated through the vasa deferentia to the testicles, giving rise in them to inflam- 
mation and enlargement. 

So much local distress must inevitably cause a great deal of general disorder. 
Febrile symptoms are commonly present ; the functions of the liver are imperfectly 
performed ; the nervous system is much disturbed, and the patient feels greatly de- 
bilitated. 

Finally, the sequel of all this dreadful train of symptoms may either be a rupture 
of the bladder, when death soon puts an end to the patient's sufferings ; or a rup- 
ture of the urethra, letting the water pass into the cellular tissue of the perinaeum, 
the scrotum, and the penis, producing immediate and enormous swelling of these 
parts, and sometimes violent inflammation, gangrene, and death ; or there may be 
fistulae in the perinaeum, the miseries of which are but little preferable to dissolution. 

Other symptoms, also, usually attend the affection, which more or less contribute 
to the distress. One of the most hazardous is incontinence of urine. The pressure 
behind the stricture keeps up a constant involuntary dribbling ; the clothes are all 
the time wet and foul, and the patient is an object of disgust and loathing, not only 
to others, but even to himself. 

The importance of proper and early attention to the approaches of stricture, must, 






274 STRICTURE OF THE URETHRA. 

I think, be readily acknowledged ; and a patient who is really thus affected cannot 
too soon consult a proper medical adviser. I, however, feel it my duty in this place 
to offer a few words of advice and caution to such of my non-professional readers 
as»may perchance read these pages. 

It has become altogether too common, of late years, among professional men, 
either from motives of gain, or from ignorance, to persuade their patients that they 
are seriously diseased, when, in fact there is nothing, or next to nothing the matter 
with them. Quacks have seized upon this idea, as it admirably suits their merce- 
nary purposes ; and they fill their victims with terrors of evils which are wholly ima- 
ginary, having no existence except in the frightful pictures drawn by unprincipled 
charlatans, and in the disordered and excited imaginations upon which they operate. 
To such an extent is this system of deception practised, that the opinion has grown 
to be quite prevalent with the public, and, perhaps, with many surgeons, that dis- 
ease of any description of the genito-urinary apparatus, betokens a stricture, and 
foreshadows all the dreadful train of sufferings which I have already described. 
Daily the quacks are startling the community with the notion that if a person have 
chordee, slight irritation of the urethra, a gleety discharge, hydrocele, indurated testi- 
cle, occasional priapism, seminal weakness or impotency, incontinence of urine, ba- 
lanitis, or any eruption on the glans penis or prepuce, if he cannot pass a stream 
of water as large as one's little finger, and as round and straight as a gun barrel, then 
he certainly has stricture, and is forthwith put under treatment for this complaint. 

Now any of these symptoms may occur, besides many others which are purely 
imaginary, and yet the patient not have the slightest kind of stricture. 

A trifling alteration of the mucous membrane of the urethra from its normal state, 
the consequence, perhaps, of some former inflammation which has long been ex- 
tinct, may so far change the stream of water as to give it a cork-screw shape, or 
broken jet. An enlarged prostate gland, occuring most frequently in persons ad- 
vanced in life, will cause a complete retention, or earlier, a diminished stream and 
dropping, with a constant desire to empty the bladder ; or the muscles of the penis 
becoming relaxed, the last drops cannot be expelled, and there is a dribbling upon 
the clothes of the small quantity of urine which remains in the urethra after the ex- 
pulsive contractions of the bladder have ceased. A difficulty of a like kind may 
arise from paralysis of the bladder ; and whatever can produce spasm, however 
transient- in its effects, may give rise to symptoms, which will either subside rapidly 
themselves, or yield to the simplest kind of treatment. 



BTBICTURE OP THE ''Ki:nii;.\ 275 

li is useful DOt only tor the practitioner. Imt lor the public to ho acquainted with 

these facts ; tor the former will practice with more skill and credit to himself, while 
the latter will ofton be raved from the jaws of ignorant or unrighteous sharks, who 
are ready to devour their Bubstance under fake pretences, and he rescued from the 

horrors of the mind, arising from the apprehension of impending distress. 



DIAGNOSIS OF STRICTURE. 

From what I have previously said, it wilf be understood that, when a patient ap- 
plies to us with the impression that he is laboring under stricture, it is possible that 
the symptoms may spring from another cause. Or they may be of a doubtful kind, 
ami therefore it is necessary to make an examination of the urethra with a bougie, 
or some other corresponding instrument, to remove the doubt. 

The bougie which is best suited for the purpose, is that made of plaster or wax, 
and should be of full size — large enough to fill the urethra without forcing it. If a 
small instrument be employed, there are two circumstances which are liable to lead 
us into a false diagnosis. The bougie may pass through the stricture without being 
sensibly obstructed, leading us to suppose that no stricture exists ; or its small point 
may become involved in the orifice of one of the follicles, or in a lacuna of the 
urethra, or in a slight wrinkle of the mucous membrane, and lead us to the opinion 
that there is a stricture, when, in fact, there is nothing of the kind. Both these 
errors it is very desirable to guard against. In the one case we should subject the 
patient to unnecessary treatment, and in the other, we dismiss him with an assur- 
ance that all is well, injuring him by losing valuable time, and injuring ourselves, in 
all probability, by sending him to consult some one else who will succeed better in 
making an exploration. 

The mode of introducing the bougie I need scarcely point out, as nearly every 
practitioner has a fanciful plan of his own, which he conceives to be superior to that 
adopted by others. Unless there is some particular reason for a contrary proceed- 
ing, I generally prefer that the patient shall be in the erect posture before me. I 
take a curved wax bougie, well oiled, in my right hand, and introduce it with the 
convexity upwards, and the handle turned towards the left groin. Having intro- 
duced the instrument in this way as far as the curve of the urethra, I bring the 
handle to the body of the patient, at the same time dexterously turning it so that the 



EXPLANATION OF PLATE. 

Figure 1, of the preceding plate, is that of an elastic catheter, intended to show the shape 
of a male urethra. Tin; particular curve was given to it in consequence of its having been 
so long retained in the urethra, as to have been permanently impressed with the precise 
form of the canal. 

Figure 2, represents an elastic bougie bent into the ordinary curve that is given to it by 
the maker. Figure 3, in outline, exhibits the same instrument with the wire drawn out 
about half an inch, which, it will be seen, has sensibly changed the shape ; while Figure 4, 
with the stilet withdrawn a little further, has more materially altered the curve. 

It sometimes happens, in practice, that there is an advantage in be.ing able to alter the 
shape of the instrument, when it becomes engaged in the urethra with an obstruction. By 
moving the stilet, this end is attained with certainty, without any further manipulation ; and 
the catheter, perhaps, will now surmount the difficulty, and pass at once to the bladder. 

277 



X 



278 STRICTURE OF THE URETHRA. 

concavity is reversed, when, if there be no impediment, by pressing gently onward 
and lowering the outer end, it will readily glide into the bladder. The operation is 
very simple when performed in this manner. There are but two natural obstacles, 
after passing the bend caused by the pendulous part of the urethra, one is at the 
bulb and the other at the triangular ligament which passes under the urethra at the 
commencement of the membranous portion. By keeping the urethra well stretched 
when the instrument is brought to the perpendicular position, until it is again de- 
pressed, and by bearing the po ; nt of the bougie against the upper surface of the 
canal, this difficulty may be avoided. If the handle is lowered too soon, whilst the 
urethra is not sufficiently stretched, the point will be carried against the triangular 
ligament at that part where the urethra is firmly attached to it, and cannot go for- 
ward until it is drawn back again the distance of about half an inch ; it then must 
be pushed steadily onward against the upper surface of the urethra, until it has 
passed the obstacle ; or sometimes this object can be accomplished by pressing up 
the bed of the instrument with the finger on the perineeum. 

It is well for the surgeon to be acquainted with this difficulty, and the mode of 
managing it, or he may diagnose the presence of stricture, when the urethra is quite 
free from such a contraction. 

Should we succeed in introducing the bougie without any particular trouble, we 
will, of course, conclude that, whatever may have been the symptoms, there is no 
permanent stricture. If, on the other hand, the instrument is obstructed, and, with 
all our management, we cannot succeed in getting by the impediment, the diagnosis 
is rendered clear — there is a mechanical obstruction, the result of disease, to be 
removed. 



CHAPTER XXIII. 

STRICTURE. — TREATMENT. 

The use of the catheter and bougie. — Surgical operations for retention. — Treatment for radical cure. 
Internal remedies. — Dilatation by bougies. — The varieties of instruments. — False passages. — Hem- 
orrhages : treatment. — Constitutional symptoms consequent upon the use of the bougie. — Cauteri- 
zation not advisable. — Incision. 

It will nearly always be the case that when patients apply for assistance they are 
capable of passing still some water, although very slowly and with great difficulty. 
The retention is incomplete. When the state of the patient is no worse than this, 
the necessity for assistance is not very urgent, and we may proceed to use our reme- 
dies upon reflection, and at our leisure. But should there be a total stoppage of the 
urine, and the patient be suffering vr v y much from a distended bladder, he must be 
relieved without delay. Our measures are now taken, not with the view of effecting 
a permanent cure, but to rescue him from the immediate terrible distress with which 
he is menaced. 

The primary object is to empty the bladder. For this purpose we use every ef- 
fort to introduce a small sized catheter. This is to be done with gentleness, and, if 
necessary, with perseverance. If we are foiled in one attempt, we make another, 
and continue them, varied in every possible way, until it becomes apparent that we 
cannot succeed. It will sometimes occur that these attempts will be rewarded with 
a favorable issue, for the complete retention is almost always owing, in part, to spasm, 
which the instrument will be able to overcome, if it can be directed to the opening in 

279 






280 TREATMENT OF STRICTURE. 

the strictured part. When the catheter has failed, we may next try a small cat-gut 
bougie. If it can be passed into the stricture, it should be allowed to remain there 
for some time, that it may soften and swell, and by this means dilate the contrac- 
tion. Upon being withdrawn, after it has been in the stricture, a small stream of 
water will usually follow it. The best directed efforts having failed, the patient, if 
strong and plethoric, should be blooded from the arm : cups should be applied to 
the perinseum, and these be succeeded by a considerable number of leeches, and the 
bleeding promoted by hot fomentations, hot baths, and whatever else can produce 
local relaxation. The bowels should be well opened by a large enema of Epsom 
salts, common table salt, and gruel ; or croton oil, common salt, and starch water. 
Bleeding, in those who are feeble is useless, and is better omitted. Opium must 
now be administered in large doses, both by the rectum and mouth. Three grains 
dissolved in two ounces of water, should be exhibited as an enema, and a grain may 
be given in a pill. At the end of three or four hours, if no benefit has been derived 
from what has already been done, the medicines should be repeated. I think it is 
also advisable to apply over the perinaeum soft poultices saturated with the tincture 
of opium, or belladonna, or ointments made of some one of the powerful narcotics. 
By this means the irritability of the bladder will probably diminish, so that the incli- 
nation to empty itself becomes less urgent ; the patient will fall into a short sleep ; 
general relaxation ensue ; the urine will begin to drop, and presently, when the spasm 
is quite removed, we have the happiness of seeing it come away in an uninterrupted 
jet. The patient is now relieved for the present, and we can adopt the subsequent 
treatment with more deliberation. 

It now and then happens that all these efforts fail in affording the patient relief. 
The only remedy left is a surgical operation. Modern authors have recommended 
five different kinds : First, to puncture the bladder above the pubis, which is the 
most objectionable: Second, to puncture it through the rectum, which may be done 
without much difficulty, but it is merely temporary, and does not remove the stric- 
ture : Third, to open the urethra from without, and continue the operation by cut- 
ting through the strictured part : Fourth, to divide the stricture and re-open the 
passage by an instrument passed through the urethra : Fifth, by a combination of 
these two last modes. 

The surgeon has now to decide which of these various plans he will select. The 
latest and best authorities condemn the operation above the pubis, as being fraught 



TRE \tmi:\ i' OF 8TRICT1 RE 



281 



with consecutive dangers, from which the other methods are more exempt, li* the 

bladder have risen high into the abdomen, together with its peritoneal covering, the 
puncture is effected in this situation by a simple division of the skin and separation 




MODE OF PUNCTURING THE BLADDEIi. 



Surgical anatomy of the Bladder. — The walls of the abdomen and pelvis have been removcij 
on the left side, a portion of the bladder excised, and the penis and prostate cut through on the middle 



, 



282 TREATMENT OF STRICTURE. 

of the recti and pyramidalis, and the bladder is perforated by a straight long trocar 
and canula. It is highly important to retain the canula, and every method must be 
adopted to insure the patient against the danger of infiltration. I should say that 
this operation ought never to be resorted to in retention of urine from stricture ; in 
cases of retention from enlarged prostate gland, it may be preferable, sometimes, to 
any of the other methods of opening the bladder. 

The operation through the rectum, when there is no considerable enlargement of 
the prostate gland to interfere, may be performed very easily, and Sir Benjamin 
Brodie, in his excellent work, seems inclined to give it the preference. The sim- 
plicity and safety of puncturing through the rectum, certainly strongly recommends 
it. Unless the peritonceum has descended lower between the bladder and rectum 
than usual, a circumstance which cannot be foreknown, and which is of very rare 
occurrence, the*re is no danger of wounding it. The canula of a curved trocar is 
guided by the finger to the triangular space marked out by the vesiculae seminales 
and peritonceum. The trocar and canula are now to be forced steadily into the 
bladder, when the trocar is to be withdrawn, and the canula pushed forward, so that 
the urine may freely escape. The instrument must be retained until the necessity 

line. The prostate is represented greatly enlarged, especially at the middle lobe, so as to have caused 
a retention of urine. 

A. Rectum. B. Bladder. C. Cavity of the bladder. 

a. Line of section of the abdominal wall b. Section of the posterior wall. c. Symphisis pubis. 
d. Small intestine above the bladder, e. Sigmoid flexure of the colon, f. Pouch of the rectum, g. 
Line of section of the peritonceum, which is seen reflected round the posterior face of the bladder, down 
to the bottom of the pouch i, which it forms between the bladder and rectum. Jc. Parietal peritonceum 
as it passes up to line the iliac fossa. I. Ureter, m. Vas deferens, running down on the inner side of 
theVesiculae seminales n, which may be seen reposing on the side of the bladder, p. Internal sphinc- 
ter muscle of thj rectum, o. Levator ani, divided near its insertion into the rectum, immediately be- 
low which is seent he external or anal sphincter, t. Penis split through the median line, z. Membra- 
nous portion of the urethra, s. Prostate, divided in the middle line. 

1. 2. 3. Puncture of the Bladder from the Rectum. 1. Left hand of the surgeon, the fore- 
finger introduced through the anus, and seen outlined with the point behind the prostate. 2. Right 
hand of the surgeon, holding trocar, which has been passed up in front of the left forefinger; the point 
of the stilet is projected into the bladder with the thumb of the right hand. 3. 

4. Puncture of the Bladder above the Pubis. The position of the trocar is outlined above 
the pubis ; the projecting point of the stilet, and the end of the canula, as seen in the cavity of the 
bladder. 



TREATMENT OF STRICTURE. 283 

tor its longer us.- has ceased. Much is gained lor the patienl by this proceeding ; 
bur, nnfortunately, much may remain to be done to complete the cure. The patient 
is relieved, but the organic obstruction of the urethra still exists. The difficulty of 
6nding a way through the natural channel is much diminished, because the pressure 
of urine behind the stricture is taken oil" and the irritation excited by this cause will 
rapidly subside. We may expect that the spasm, which, probably, has been the 
cause of complete retention, will now relax, and that the water will pass in the same 
manner as it did before the accession of the paroxysm. Should this not happen, or 
should it be found impracticable to insinuate the bougie under the new and more 
favorable circumstances, another cutting operation has to be performed; and it is 
this fact which renders puncturing through the rectum objectionable. 

Another method of operating is to uncture the urethra through the perina?um. 
There are several ways of doing this, and, although it is free from danger, when 
properly executed, it is a more formidable undertaking for the operator, and much 
more painful to the patient than the one last described. The operation of Mr. 
Guthrie, one of the surgeons of the Westminister hospital, I believe to be the most 
efficient, and I prefer it to any of those that I have seen recommended by others. I 
shall quote his own account of the order of proceeding. 

" The patient being placed as in the operation for stone, a catheter, or sound, is to 
be passed down to the stricture, and held steadily against it. The rectum having 
been previously cleared by an enema, the forefinger of the left hand being duly 
oiled, is to be introduced into it, and the state of the membranous part of the urethra 
and the prostate, are to be carefully ascertained. The principal object in introdu- 
cing the finger, is to ascertain the relative situation of the upper part of the rectum 
and the urethra, which latter part only approaches to, or is almost in direct applica- 
tion to the rectum, near the termination of its membranous part and the commence- 
ment of its prostatic portion. There is a certain distance, which is greater or less 
in different individuals, between the last inch of the rectum and the urethra placed 
above it. The two parts form two sides of a triangle, the apex of which is the pros- 
tate, the base, the external skin ; and it is within the two lines of the triangle that 
the operation is to be done. The surgeon taking the catheter in his right hand, 
whilst the forefinger is applied to the upper surface of the rectum, moves the point 
upwards and downwards, so as to convey to the forefinger of the left hand a know- 
ledge of the situation of the extremity of the instrument, and particularly of the dis- 



284 TREATMENT OF STRICTURE. 

tance between them, and which the motions given to the catheter by the right 
hand will clearly indicate. The thickness of the parts between the obstruction and 
the rectum can be estimated with sufficient accuracy, both at the point where the 
left forefinger is applied, and at the surface of the skin. The next step is to divide 
the tissues intervening between the upper surface of the rectum, and the under sur- 
face of the anterior and middle portions of the membranous parts of the urethra. 
This is to be done by a straight, blunt-backed, narrow, sharp-pointed bistoury fixed 
in its handle ; the point of which is to be placed on the skin, a little above the verge 
of the anus, the cutting edge being upwards, the blunt back towards the rectum, 
the handle being a little depressed, the point somewhat inclined upwards. The 
degree of inclination necessary to carry the knife inwards for the distance of an 
inch, and clear of the rectum, will be indicated by the finger in that part ; and the 
eye of the operator should correspond with the forefinger, so that the bistoury may 
be steadily passed in to that extent, and then carried upwards and brought out in 
the exact median line, making an external incision of at least an inch and a quarter* 
to an inch and a half, as regards the external parts. If the perinseum is much har- 
dened, and consequently unyielding, a transverse, curved, or crescentic incision 
should be made across it, the centre of which should correspond with the raphe, 
and be one quarter of an inch above the verge of the anus, or as near that distance 
as may be, with due regard to the safety of the rectum. This gives room, and 
allows the parts to be separated as much as they will admit. The wound having 
been sponged and examined, the surgeon should again introduce the bistoury in the 
median line, the point being directed upwards and backwards towards the urethra, 
and he may then deepen the cut, without fear, for the forefinger in the rectum will 
always inform him where the back and the point of the bistoury are. The opening 
will now be sufficiently large to allow the operator to lay aside the knife, and to feel 
for the urethra with the point of the forefinger of the left hand, keeping the end of 
the catheter steady against the stricture, which will be readily felt, and through 
which the catheter will now often pass with a little pressure. If it should not do so, 
and the point of the forefinger does not go beyond the stricture and touch the sound 
part of the urethra, which may or may not be dilated by the urine, the knife is to be 
resumed, and the forefinger being placed in the wound, on the outside of the rec- 
tum, which is to be depressed as much as possible, the back of the knife is then to 
be turned to it, and whilst the patient strains, the point should expose and open the 



TRE \tm BNT OF BTRICTURE 885 

urethra. It will not be necessary 1o go so far bark, however, and the membranous 

portion may be opened at its middle part, with every advantage, and with perfect 

tv to the intestine. A tolerably good anatomist and Burgeon will open the nre- 

thra in this ua\ sooner than the mode of doing it can be described, the urine will 

make its escape, and the patient be at oner relieved. The stricture should now bo 
divided, and the catheter carried on into the bladder." 

The directions for the operation which we have just cited from (iiithrie seems very 
complex, and yet I am inclined to look upon this method, all things being considered, 
BUperior to any other. It is perfectly safe, and promises entire success. 

The other operations it is unnecessary to describe, and the more especially as I 
cannot advise them. W hen cutting instruments are demanded to relieve stricture 
situated beyond the bulb, there is no mode having so much to recommend it as 
either this in the perineeum, or that through the rectum. 

I will add, that an operation on a patient, unless an actual necessity exists, would 
be perfectly inexcusable ; and, fortunately, this is indeed extremely seldom. By ju- 
dicious manoeuvring nearly every case will yield to the gentler methods — even the 
most unpromising will relent before the assiduous efforts of a cool and persevering 
surgeon. 

TREATMENT FOR THE CURE OF STRICTURE. 

It will be observed that what we have hitherto said in relation to the treatment 
of stricture, has referred rather to the symptom of retention of urine, than to the 
removal of the stricture itself. 

1 shall now proceed to furnish an account of the various means, each having its 
partizans, most commonly resorted to. General treatment, ordinarily, is not required, 
but if the tendency to spasm be increased by any constitutional derangement, such 
in excessive secretion of lithic acid by the kidneys, which may be known by the 
formation of small calculi, or of red sand, or lithate of ammonia, then the habits of life 
demand adjusting; and the exhibition of alkalis, purgatives, and whatever other reme- 
dies the particular nature of the case may suggest, must not be neglected to bring 
the system into healthy action. So also, if the urine be alkaline, a liberal allowance 
of good food, and the administration of opiates, the mineral acids and tonics, will be 
productive of much advantage in aid of the local measures. Regular living in all 



286 TREATMENT OF STRICTURE. 

cases is advisable, and riding on horseback, or violent exercise, must be strictly pro- 
hibited. 

Stricture being a reduction of the capacity of the urinary channel, it is obvious 
that the grand indication is to restore the canal to its original dimension. When 
there is an obstruction, the first idea which occurs, is to attempt its removal by in- 
struments that can make their way to the bladder. Hence the use of bougies and 
catheters. These are made of different materials — some are metallic and others 
plastic; some unyielding and others elastic. Surgeons have their partialities — 
perhaps mere prejudices, in using one or the other of the various kinds, but a good 
surgeon will never wed himself to any particular instrument, or medicine, in the re- 
moval of disease. He who does so, is deprived, unnecessarily, of some of the re- 
sources of his art. He is guilty of the same folly of which a man would be guilty, 
who, in engaging in a conflict with a strong enemy, should fool-hardily tie up one 
of his hands, so that it should be useless, merely from the ridiculous vanity of dis- 
playing the more strikingly his own superior strength. Whoever relies upon a single 
remedy, under the protean shapes in which disease is displayed, reduces himself to 
the rank of the empirics, and reminds one of the quack nostrum-venders who offer 
to furnish the public with a universal medicine, that will cure every malady that 
" flesh is heir to." 

Dilatation is the most natural method of cure, and the experience of the profession 
has shown it to be the most preferable. Bougies for this purpose have been in use 
for at least three hundred years, and Alphonso Ferri of Naples, one of the old 
writers, maintains that they were known to Alexander of Tralles, a surgeon who 
flourished in the sixth century of the Christian era. 

Dilatation of a stricture presupposes that there is such an opening through it as to 
allow the insinuation of a bougie. When this is impracticable, by mild measures, 
it is a very reprehensible practice to punch a way through, or to continue poking at 
it for a long time in the hope of at last attaining the object in view. In this way 
much injury is often done to the parts, and the evil is rather increased than lessened. 
In all these cases, my plan is to introduce a bougie of moderate size, until its point 
is arrested by the obstruction, and I request the patient to keep it firmly but not 
forcibly, in contact with the stricture, as long as he can bear it with comfort, or for 
perhaps an hour. At the end of this time, it very often happens that the instrument 
will now go forward without much difficulty, and we may at once reach the bladder. 






[•RE \tmi:vi OF 3TRTCTURB. 287 

The mode in which this change is brought aboul I am unable to explain — it. may 

be by fatiguing the parts which had resisted, or it may be that ill some other way it 
allays irritation. Having got llie instrument through the canal, the subsequent 

treatment becomes comparatively easy. It has bees recommended by Velpeau and 

certain others, to dilate rapidly — that is to say, soon after one bougie lias been 

removed, to follow with a size larger, and this to he repeated until the largest has 
been made to enter the bladder. This has been done in a few- hours, or at most in 
•ry few days. This practice I believe, is mainly confined to the French sur- 
»ns, and it is one that has objections, the most important of which, seems to be, 
that it produces only temporary effects* It acts, I apprehend, on the same principle 
that rules when we stretch inert matter. It must be clear that treating living tissues 
in this way is physiologically wrong. There is not sufficient time given for the 
dilated part to acquire new actions, and conform itself to the altered condition that 
is imposed upon it. No time is allowed for vital changes to be effected, and, there- 
fore, we can only imagine, either that it is merely stretched out by the application of 
mechanical force, which overcomes its contracted state, or else that the violence and 
haste of the proceeding has lacerated the urethra, and probably produced a severe 
inflammation, which in the end, will be found to have done more harm than it has 
done good. It is, in line, a method which does not commend itself to my under- 
standing ; consequently, I do not practise it, nor can I advise others to try it. 

The frequency with which the bougie may be used with benefit to the patient, 
and without subjecting him to undue irritation, depends, in some measure, upon the 
constitution of the person upon whom we operate. Sometimes it may be introduced 
cverv day, but, at others, it may be necessary to allow two, three, or more days to 
elapse, before it can be repeated. As we proceed, the urethra accommodates itself 
to the new usage, and feels less the irritation which was excited on the first attempts. 
If many days are allowed to pass without a reapplication, it will be found that the 
parts are returning to their former state. 

The most important part of the treatment of dilatation, however, is in keeping the 
instrument in the urethra for a considerable period each time it is introduced. 
Hours together are not too much ; and I advise, even, that patients shall sleep with 
it through the night. This is my practice, and I know it answers far better than 
the trifling mode of putting the bougie into the stricture, and in a few minutes after 



288 



TREATMENT OF STRICTURE. 



withdrawing it. Patients often come to me who have been thus treated, and, as a 
matter of course, have received no benefit of a permanent kind. 

Various are the shapes of instruments which have been used for 
the purpose of dilating stricture. Some surgeons have employed straight 
metallic bougies, and when the stricture is anterior to the bulb, these 
are as good, if not better, than the bent ; some employ the cylindrical, 

I or those of equal diameter from one end to the other ; others use the 

if conical, while there ere still others who have a fancy for what are called 
the bellied or fusiform. There may be certain peculiar cases in which 
one of these varieties is superior to the others, but I confess that the old- 
fashioned cylindrical flexible bougie, well made, I have always found 
admirably to serve all my purposes, and I have not the slightest wish to 
change it for anything new. When I can introduce it in the stricture, I 
never fail in accomplishing a cure, with comfort to my patient, and to my 
own satisfaction. This, I am sure, is as much as can be said in favor of 
any of the later kinds. The plate exhibits the shapes of those which I 
have been describing. 

There are some surgeons, and among them Mr. Phillips, who deny 
that the bougie is a curative agent in treating stricture. This 1 am 
not prepared to admit. If the proposition had been stated differently, 
viz. : that the bougie is not always a curative agent, it would be 
allowable ; for, no doubt, it often occurs that contractions return, espe- 
cially after they have been rapidly removed by this instrument. But 
may not this be ascribed, in many instances, to incomplete cures, which, 
had the treatment been longer continued, would have ended in complete 
ones 1 The pressure exerted in dilatation, I cannot help believing, ex- 
ercises a powerful influence in promoting an absorbent action upon the 
conical F^sfem adventitious or morbid production composing the obstruction. Such we 
know to be the ordinary effect of pressure on the natural tissues ; and we also know 
that those accidentally developed are still more subject to this pathological law. It 
therefore is a legitimate logical deduction from this well settled vital principle, that 
the same effect will follow the same antecedent conditions. That patients are often 
permanently cured, my own experience furnishes me with the best evidence for 
believing. Owing, however, to the circumstance suggested above, it may, indeed, be 



TREATMENT OF BTRICTTJRE. 



289 



xhc fa , t , thal patioma are sometimes only relieved. Even this is gaining much. 

Hence it ia proper, when a Burgeon is taking 

leave of his patient, to admonish him against 

neglect of symptoms that may indicate a 

return of the disease. He should be instructed WW 

in the art of introducing the instrument tor 

himself; and it would be advisable for him, 

isionally, to pass it through the urethra, 
with the view of keeping it open. Once a 
month, or perhaps six months, or even a year 4 
may be often enough to save him from any fu- 
ture trouble. In doing this, he should be ap- 
prised of the danger of making false passages, 
bv using violence in forcing the instrument 
forward, when the point of it becomes engaged 
with the lacuna? or plica? of the mucous mem : 
brane. By whomsoever the bougie may be 
used, — surgeon or patient — it should be a 
precept, always to be borne in mind, that 
much mischief may, in this manner, be done, 
and all the evils of a diseased urethra become 

atly aggravated. It is a very common oc- 
currence for persons to prese- themselves to 
me for assistance, in whom false passages 
have been pierced by ignorant and energetic 
operators. It is a very nice point to determine 
what amount of force may be employed with 
safety to the delicate textures by which the in- 
strument is invested. With a certain class of 

This plate exhibits the cylindrical bougie, and a cauterizing instrument, which I believo to be the 
only proper one as yet known for cauterizing the mouths of the ejaculatory ducts, in seminal weakness. 
Lallemand's pwte-caustique for this purpose, is liable to at least one very serious objection, and which 
is enough to condemn for ever its further use. The cup, in his instrument, that contains the caustic, is 
attached to a flexible spiral rod, and is projected beyond the end of the catheter to the parts intended 




290 



TREATMENT OF STRICTURE. 




men who continue to beguile the community into 
a belief that they possess superior qualifications, 
when in truth they are wholly without knowledge 
of human diseases, the favorite practice is a sort 
of horse doctoring ; and what they lack in skill, 
they supply in strength. Their operations are 
conducted with an abiding faith in a mathematical 
principle of treatment — if gentle force be good, 
strong force will be better, — as one pill is to a 
given result, so are two pills to double that 
result ! 

Urethra and Bladder. 

to be cauterized, where it is capable of being turned around, sbould the surgeon desire it. The objec- 
tion is rather to its mechanism than its theory. When the caustic cup is thrust forward to be used in 
the urethra, there is much danger that its slender neck may break, and still more in turning it, thus 
leaving it behind in the prostatic portion of the canal. It has once broken in my hands — the first, and 
I arn sure it will be the last time. I can scarcely imagine that any one could be more alarmed, for the 
moment, than I was. I felt it give way distinctly. Very gradually I withdrew the instrument in the 
proper direction, and it fortunately happened that the separated portion followed the catheter, and 
dropped upon the floor. Whether it was not wholly detached from the rou, or whether it was forced 
outwards by the contraction of the urethra, I am unable to say. But I can say that its appearance, 
when it fell to the floor, was to me a matter of the most hearty rejoicing. The patient neither heard it 
when it struck the floor, nor saw it, nor was there anything in my manner which betrayed to him the 
imminent danger he had escaped. He was a gentlemen of distinction, and such an occurrence, had it 
terminated in leaving the broken piece behind, would have been sufficient to destroy the standing and 
reputation — I was about to say — of the most distinguished in our profession. The same accident has 
happened to others, how many times I know not ; but I know of one instance in which it proved fatal. 
A physician of Buffalo was using it upon himself, when it broke off in the neck of the bladder, and was 
the cause of his death. The fact is sufficient, I should think, to deter any one, however experienced in 
the use of instruments, from employing it. The instrument represented in the plate is not open to this 
objection. No such consequence can possibly result from it. 



The above plate shows the urethra and bladder, with the porte-caustique introduced, as in the act of 
cauterizing the mouths of the ejaculatory ducts. 1 . The bladder. 2. The penis. 3. The porte-caus- 
tique. 4. The caustic applied to the ejaculatory ducts. 

The instrument is first introduced into the bladder. If there isjao danger of the patient's fainting, I 



i u:\tmknt «»!■• stk-ic I i i;k. i")\ 

A not uncommon accident accompanying the use of the bougie, are hemorrhage! 
from the urethra. Bleeding sometimes happens to b rerj considerable amount, bill 
there is nothing in it tlmt need excite any alarm. With all the tenderness that we 
ran show to the disease, consistent with doing anything effective, a copious How of 
blood may follow the introduction of the instruments Prom the sum of force exer- 
cised, we are sure that the urethra could not possibly have been torn, or in imv other 
■tanner injured, and hence we infer that some part of the canal is suffering from ex- 
cessive vascularity, and probably that the depletion will have a favorable influence 

on the further management of the cure. Should the discharge show ■ disposition 

to continue until it might become exhausting, it generally may be assuaged by 
astringent injections; or, if these should fail, by the introduction of a full-sized 
bougie, sufficiently large to make pressure over the bleeding part ; or, by what, in 
very severe cases, is yet more effectual — making external pressure over that spot 
of the urethra, from which the hemorrhage is taking place. In doing this, a piece 
of cork is as good as any article that can be employed. 

To know where the pressure is to be made, the patient should be requested to 
expel all the coagulated blood out of the urethra ; and, as the bleeding usually pro- 
ceeds in these cases from that part which is anterior to the triangular ligament, w 
ascertain, in the first instance, by pressing along on the outside of the urethra, be- 
ginning as far behind as possible, the precise point whence the blood escapes. If 
pressure be made behind the spot, it is evident that we produce no effect. We then 
advance a little forward, and try again ; if the blood still flows, we move further, and 
thus we continue until we find that the pressure has cut off the effusion. We judge 
now, that the bleeding surface must either be directly beneath the line of force, or 
else a very little behind it. In this way it is commonly easy to stop the most obsti- 

prefer to pass it while he is standing before me. The moment the opening in the end of the instru- 
ment enters the bladder, it will be known by the escape of urine. It must now be withdrawn, just 
sufficiently far to stop any further issuing of the water, which will place the slit directly over the mouths 
of the ejaculatory ducts. The rod holding the caustic must be at one© drawn forward, so that its cup 
will come exactly opposite the opening in the catheter, which will bring the caustic in contact with the 
ducts and prostatic portion of the urethra. Some surgeons prefer using the dry powdered nitrate of 
silver, while others use it in the solid state. I am governed by the condition of the parts, as to what 
material I use. Sometimes I use the dry powder alone, but most frequently mixed with simple cerate 
or gum arabic. At others, I use burnt alum, and sometimes sulphate of copper, adulterated. 



292 TREATMENT OF STRICTURE. 

nate hemorrhages. Placing a cork or pad upon the point, the patient will usually 
be able to make proper pressure upon it better than another person can do it for 
him. 

An accident which occasionally follows the use of bougies, is sudden constitutional 
disturbance ; in the young and middle aged, there may be sickness and fainting, — 
in the old there may be rigors. These symptoms are of no particular consequence, 
except so far as they produce temporary inconvenience. They are the result of 
much susceptibility of the nervous system, combined with the local irritability of the 
urethra. After a few applications, such untoward effects cease ; or, if necessary, 
they may usually be prevented by administering, a short time previous to the intro- 
duction of the instrument, a full dose of opium or laudanum. 

Such facts as these should never be forgotten, for if the practitioner is not aware 
of them, the patient may be alarmed or unnecessarily suffer, and the surgeon, be- 
coming embarassed by the unexpected complication, loses his self-confidence, and, 
what is even worse, the confidence of others. This to him is a most serious loss, 
for it is his whole stock in trade, which, being once destroyed, he becomes a pro- 
fessional bankrupt, and will find it much more difficult to regain his position than 
the insolvent merchant, who can start anew upon borrowed capital. Both may be 
the wiser for the lessons they have dearly paid foi, ^ut the trader with his replenished 
money-bags, can go into the market and at once command business ; while the 
doctor, whose capital is his scientific knowledge and the good opinion of the world 
around him, is compelled to stay at home, and often hopelessly wait for it to come 
to his doors. 

When we are able to pass a full-sized bougie through the strictured part, it may 
be repeated at longer intervals of time. At first once a week ; then once in two 
weeks ; next once a month, until we have reason to feel satisfied that the dilatation 
is complete, and that our further services are no longer required for a satisfactory 
termination of the case. 

Cauterization is another method which has been greatly in vogue for the cure of 
stricture. Escharotics are not of recent use in such cases, for they appear to have 
been resorted to at least four centuries ago, by Alphonso Ferri, Alderato, Amatus 
Lusinatus and others, with much success in destroying carnosities of the urethra, as 
they then commonly called all obstructions. In those early times, the caustics were 
composed of several ingredients, and there were several different formulae for pre- 



TUKATMKVI QF BTEIG PI SI ^ ,: * 

paring them. The one which \\;is commonly used l>y Ambrose Pare, was 
composed of : 

Powdered Sabine, 3ij. 

Ochre, ^ 

Antimony, > aa i. 

Prepared Tatty, ) 

William Loiseau treated Henry IV. of France, successfully, by means of the cau- 
tery, employed much in the same manner that it was employed by Pare. It appears, 
however, notwithstanding its claim to an origin of ancient date, that at the begin- 
ning of this century, it had been quite forgotten, and was at that time revived as 
something new in surgery. Among modern surgeons, John Hunter seems to have 
been the first to try its virtues. Sir Everard Home brings forward a great number 
of cases in his work on stricture, to prove its efficacy and give it fame. They used 
the nitrate of silver, and upon the whole, this is probably the best of all the different 
caustics which have been tried. 

Soon after the lunar caustic was so strongly recommended by Home, Mr. 
Whately came before the profession with the " kali purum," or the potassa fusa of 
the late pharmacopoeias ; and made for it the most extravagant pretensions. All 
the great authorities in the healing art having got astride of this hobby, the profes- 
sional crowd could do no less than follow after. Cauterization was the great remedy 
of the day, to the neglect of all other kinds of treatment. Every variety of stricture 
was treated with burning, without discrimination, and, it cannot be doubted, that 
there was much mischief done, and that there were numerous failures. Though 
not abandoned, its use in England has become much more restricted, and this is 
particularly the case with the caustic potash. Mr. Wade, a London surgeon of 
some note, has lately made an attempt to revive the employment of this article, and 
has furnished in his work, some very good cases of its therapeutical effects ; but, 
nevertheless, it seems to meet with no favor from the great mass of the profession, 
and the nitrate of silver is generally thought to be preferable. 

Caustic is supposed, by its advocates, 1st. That it can allay irritation and spasm ; 
2d. That is can destroy a long and narrow stricture ; 3d. That it works a perma- 
nent cure. The experience of every medical man, establishes the first proposition. 
It certainly possesses the admirable property of quieting the irritation of membranes, 



294 TREATMENT OF STRICTURE. 

in a very decided and remarkable manner ; but this, I believe, is as far as its useful- 
ness extends. 

Can it be possible, that by its escharotic action, it is capable of removing the 
indurated substance which so commonly is the chief cause of stricture 1 It will, 
undoubtedly, produce an eschar, but this is so exceedingly thin, that the length of 
time which would be necessary to remove the whole mass of obstruction by this 
process, wonld be tediously long, if, perchance, it succeeded at all. But, it must not 
be forgotten, that the reparative actions are going on at the same time that we are 
pursuing the destructive. The thin film which we burn away, will, in a very few 
days, be restored, — >as soon, indeed, as it is advisable to re-apply the caustic. If we 
use it oftener, or longer, so that its effects are more potent, then we may anticipate 
consequences, extremely troublesome to manage, and to which no patient will 
willingly submit. Violent inflammation must assuredly be excited, and all the 
symptoms of stricture, as certainly increased. But suppose that it does actually 
eat away the induration, what is the condition of the part that remains 1 We must, 
of course, at the outset, destroy the mucous membrane, and, when the effused matter 
has been eroded, we have an ulcer, with its base resting in the subjacent cellular 
tissue, or, what is more probable, in the corpus spongiosum. We are rid of the 
stricture, it may be assumed, after much suffering and persevering effort, but, we 
have left behind, a very ugly sore in the urethra, that must in the end, be healed up. 
When this purpose is attained, how then will the case be likely to stand 1 We 
shall find that there have been new extravasations of lymph, and that we have got a 
new stricture, formed by a hard cicatrice, more distressing than the original. With 
the nitrate of silver, I do not believe, as I have already suggested, we need fear any 
such caustic effects. We may kindle an inflammation by its improper use, but we 
shall not be able to cause deep sloughing. An estimate of its action in the urethra 
can be formed, by observing how it acts on such mucous membranes as lie under 
our immediate notice. If it be applied to the membrane of the mouth, we see but 
little more than a coagulation of the mucus, and a crisping of the epithelium. The 
same thing happens in the vagina. When frequently applied to the same spot, 
there are still to be seen no very destructive effects. It then is fair to conclude, that 
when introduced into the urethra, precisely the same consequences ensue. To my 
understanding, it is plain, that, as an escharotic, the nitrate of silver is quite useless, 
if not worse than useless, and that it can exercise no chemical influence, in the 



TRE \ imi:\ r OF si i;ic fURE. 







removal of permanent stricture. Can it then in any other way, do good service 111 
this cause ! There is hut one mo le in which this is probable, and 

that is by its acting as a common stimulant — Increasing thus the 

n \\ action of the absorbents, and indirectly curing the contraction. It. 

is of such cases that we read, in those authors who have been so 
enamoured of its advantages. But, after all, how does it appear 
that this is in any wise superior to the practice of dilatation, by 
means of the simple bougie 1 Indeed, it is not at all unlikely, that 
one-half of the good, at least, in those cases, was derived from the 
mechanical effects of the naked instrument. The porte-caustiquei 
of which we have furnished figures in the accompanying cut, is 
passed into the strictured part, and, were it used unarmed, would, 
I conceive, give rise to nearly the same series of phenomena. If 
the stricture be very irritable, it is unquestionably useful ; but if not, 
my opinion is, that the process, conducted by the plain instrument, 
will accomplish just as much, or even more than cauterization, if 
dilatation be omitted when the caustic is employed. 

The fact is, it is often the case, when the cautery is had recourse 
to, that the preliminary steps are the use of dilating instruments, to 
prepare the road for the admssion of the caustic-carrier. The 
cure, therefore, is already half accomplished by what are deemed the 
incidental means. Is it not evident, that the practice would not be 
bad, if such means alone, unless there were special indications for 
the nitrate of silver, were entirely relied on for the completion of the 
treatment ? 

To what results does this argument conduct us ? 1st. That 
mco ^cau. L u ?J queT nd ' 3 nitrate of silver is a valuable agent in the treatment of irritable stric- 




06 



Ricord employs cauterization from before backward, in the following way : he introduces a canula, 
enclosing a stilet, armed at its extremity with a little cup ; as soon as the canula is in contact with the 
stricture, the cup containing the powder of the nitrate of silver, which has been melted by submitting it 
to the flame of a candle, is made to project, and thus the part is cauterized. 

In order to cauterize the parietie3 of a stricture, Lallemand's, but above all, the instrument I have 
described on a previous page, must be employed. The instrument should be either straight or curved, 
according to the seat of the stricture. 



296 TREATMENT OF STRICTURE. 

tures, because it allays irritation and the consequent spasm, and hence affords rapid 
and great relief. 2d. That it is of no use in destroying long and narrow or indu- 
rated strictures, and that it will not, often, alone effect a permanent cure. 3d. That 
in conjunction with bougies, it is of great assistance in such cases as maybe accom- 
panied with much morbid irritability, so that the bougie cannot be used without 
inflicting severe pain. 

Little need be said of the potassa fusa. As a caustic, it possesses much more 
power than nitrate of silver, and if indiscreetly used, will assuredly give rise to the 
most unpleasant consequences. Its general effects are the same, and may there- 
fore, be employed to fulfil the same indications. Its advocates allege that it gives 
less pain than lunar caustic, and that it often succeeds like a charm, when the other 
remedies fail. They recommend that the quantity should be very minute, so that it 
cannot do injury to the sound parts of the urethra. Used in this manner, I have no 
doubt that it may safely be resorted to whenever a caustic is required ; but, for all 
the purposes for which I ever employ a cautery in these cases, viz. : to allay irrita- 
tion, the nitrate of silver is quite sufficient. Therefore I have had no occasion to 
try the virtues of the potash caustic. I confess, besides, that I have always enter- 
tained towards it an aversion, amounting to a kind of prejudice, from observing the 
rapidity with which it liquifies and spreads itself beyond the bounds within which 
it is intended to be applied. All the objections that I have urged against nitrate of 
silver, may also be urged against potassa fusa ; and, as it has nothing special to 
recommend it, I see no good reason why it should be expected to supersede the 
milder and more manageable caustic. 

Treatment by Incision. — This mode of removing stricture was practised three 
centuries ago by De Vega and Diaz, and at the beginning of the seventeenth cen- 
tury by Mayerne, in France. After that time until about twenty years ago, it appears 
to have gone quite out of use, at which period, an attempt was made to revive it 
again. Many cutting instruments have been invented, but there are greater or less 
objections to them all. When the stricture is seated as far back as the curve of the 
urethra, and particularly if there be much substance to cut through, I am decidedly 
opposed to the employment of all such instruments. The operation is then neces- 
sarily one of difficulty and danger, and nothing but a necessity for overcoming a 
danger of greater magnitude, can justify its performance. When a cutting operation 
is imperiously called for, by the great suffering of a patient, it may be a question 



TRE \tmi:\t OP STRICTURE 



207 







with ilir surirmn, whether dividing Ihfc stricture Willi a knife internally applied, may 
not bfi done in preference to the external operations, sneli as I have already de- 
scribed. 

'1 be only instances in which I ever adopt this practice, is when I have to deal 
with a hard, grisly, or Cartilaginous stricture, situated anterior to the curve, so that I 
can reach it with a straight instrument, and can, consequently, divide it freely with- 
out danger of wounding Ibe Urethra in other parts. If the stricture be like a drum- 
head, or septum, or valve stretched across the canal, and of a hard nature, there is a 
decided advantage in resorting to this method, and when I meet 
with such cases, I very often use my knife. The chief benefit 
derived from this treatment, is the rapidity, and I may add the cer- 
tainty with which I effect a cure. To remove the indurated stric- 
ture with the bougie alone, is always a very tedious process, and 
both patient and surgeon grow tired, long before any great and 
essential service has been done by it. 

The instrument I use is represented in the margin. It is a straight 
canula, having on its extremity a probe, about an inch in length. 
A stilet passes through the canula ; and, at its outer extremity, a, 
is attached to a spiral spring, which retracts the knife within its 
sheath after it has been thrust forward to make an incision. At its 
inner extremity is a blade with a rounded edge, concealed, when 
introduced, within the bulb or sheath b. The figure shows the 
knife pushed out as in the act of cutting. 

I never attempt to use this instrument, until I am able to pass the 
probe point within the stricture. There is also in the margin, a cut 
of the instrument employed by Ricord, for the same purpose. 

If necessary, by the size and shape of the stricture, I withdraw 
the instrument a short distance, turn it a little in the urethra, and 
perform the operation as before, cutting in a new place. I have 
sometimes thus incised in three different parts, and I am able to 
add, with complete success. 

The stricture being divided, a bougie is introduced to the 
bladder. Afterwards, a piece of bougie is placed in the urethra, 



Ricord'3 



298 



TREATMENT OF STRICTURE. 




as shown in the cut, to prevent a reunion of the divided surfaces of 
the stricture, and is only taken out, when the patient has occasion to 
make water. Keeping it in this situation for a few days, absorption 
to a great extent has been accomplished, and it may now be removed. 
Generally, no further treatment is required ; the patient can void a 
full stream, and the cure may be considered as perfectly achieved. I 
have now presented in a brief manner, my opinions of the pathol- 
ogy of stricture, and have described the treatment which I have 
found to be the most successful. These will be amplified in another work ex- 
pressly devoted to this subject, which I have now nearly ready for the press. 

What I have recommended is not mere speculation, but is the result of a very 
extensive practice. For ordinary cases, I always find the bougie and dilatation 
quite competent to effect a satisfactory cure. The cautery I entirely reject as a 
curative agent, and only use it to allay irritability, so that I can perform, the more 
readily, the process of dilatation. The stiletto, for cntling in the deep parts of the 
urethra, I utterly denounce as unphilosophical, unsafe, and most of all, unsurgeon- 
like. Its employment is groping in the dark ; and there is no experience, no length 
of practice, no anatomical knowledge, that can free it from the imputation of rash- 
ness. No man, I care not how great be his professional standing, should ever have 
an opportunity of thrusting his stiletto into me, so satisfied am I, that the most serious 
injury may be inflicted by the operation. But a cutting instrument, such as I have 
found useful and safe, and under such circumstances as I have described, may be 
occasionally called into requisition with decided advantage, and without the slightest 
danger, in skilful hands, of doing harm. 



CHAPTER XXIV. 

STRICTURE— CASES ILLUSTRATING ITS TREATMENT. 

CASE I. 

A. B. aged 39, consulted me May 6th, 1844, and stated that he had always enjoyed 
good health until he contracted a gonorrhoea in 1834. From that unfortunate time he 
dated the commencement of his trouble. He had tried the skill of a number of 
medical men, but, notwithstanding, the c ] ap stuck to hin closer than a brother for 
nine long months, two months of whic! time he hod beer, confined to his bed with 
swollen testicles, and sympathetic buboes. The remedies he used embraced every 
kind of article except injections. 

He believed, he said, that he had been inoculated with all the clap poison in the 
city, for his penis had swollen up as large as his arm ; discharged an immense quan- 
tity of matter ; was subject to a terrible chordee, and, what was worse than all, the 
skin contracted in front of the glans, to such a degree, that he could not even uri- 
nate ; and it looked like a big well-filled purse, with a closely drawn string. This 
phymosis a doctor was obliged to relieve with a knife ; and after a tedious time of 
nine months, he regained a tolerably good condition. 

About sixteen months afterwards, he began to notice some difficulty in making 
water, to which he paid but little or no attention for two more years, when the 
stream had become so small, as to make it troublesome to evacuate his bladder. 
He then applied to a medical man for assistance. He was treated with bougies, 

299 



300 TREATMENT OF STRICTURE.— CASES. 

and so far cured as to enable him to make water with but little difficulty, for some 
time ; but in 1840, the obstacle to urinating had again become apparent. He was 
now poor in pocket, and was therefore obliged to let it take its own way, until his 
application to me. 

The stricture by this time had become so bad, that it was only with the greatest 
difficulty that he could void his urine at all ; while perinoeal fistulse were threatening 
to make his situation still more wretched. The meatus urinarius and glans penis, 
presented the characteristic appearance of long standing strictures — being swollen 
and hard, with a peculiar white and shining look, resembling to use a common ex- 
pression, whit-leather. 

TREATMENT. 

« 

I succeeded, after a few trials, in introducing a small bougie through the stric- 
ture, which was situated three and a half inches from the mouth of the urethra. 
For two weeks or more, I continued to pass different instruments, sometimes steel 
ones, and sometimes the hardest kind of conical gum elastic, but without doing 
much, if any good. The stricture encircled the urethra, and was unwilling to yield 
to the treatment for dilatation. Without wasting any more time, I determined to 
cut the stricture. I divided it at once in three places, and introduced, without the 
least difficulty, a large hard gum bougie, the end which I cut off, leaving only 
enough to fasten a piece of tape to, which I carried around the hips and made fast. 
This I requested him to we.ar constantly for one week, and only remove it to uri- 
nate ; in the meantime, to keep his room, and be careful not to do anything which 
might cause injury to the parts. 

My directions were strictly attended to. Ten hours after the operation, a consid- 
erable discharge commenced, and continued until the fifth day, when the quantity 
diminished. I now withdrew the piece of bougie, and put in another of larger size, 
which he wore for ten days longer. The discharge gradually lessened, and two 
weeks afterwards, being able to make as large a stream of water as he ever could, 
I stopped it entirely, with a few injections of a decoction of green tea and alum. 

I saw this man after the lapse of nearly four years, and found him in perfect 
health and prosperous circumstances. He had not, as yet, had any symptoms of 
a return of the stricture ; and upon examining the urethra, I could not discover the 
slightest vestige of induration. I feel quite convinced, that he never will be troubled 
again with the same stricture. 



TREA rMENT OF STRIC Tl HE. —CASES. tfOl 



CASE II. 

C. P. aged 36, a gentleman of considerable distinction, from South Carolina, came 
to consult me, August 4, 1844. He stated that he had a very bad stricture in the 
urethra, of long standing, which was brought on by a gonorrhoea. From motives of 
delicacy he had neglected doing anything for it in his part of the country, fearing 
that it might reach the ears of his family, <fcc. He said that he had not passed any 
urine through the natural channel for three years, but that it found its way out 
through the parts behind the scrotum, by two fistulous openings. I expressed my 
surprise, that he should have allowed any considerations to prevent him from attend- 
ing to a duty so important, long before. His reply was, "so it is — such were my 
feelings upon this subject, that I would rather have died than let my family know 
anything about it ; and in fact, I have long expected that I should never recover 
from the loathesome and disgusting disease." 

TREATMENT. 

I examined the parts with a bougie, and found the urethra completely plugged up 
in its membranous portion : at this time I could not pass any instrument. I told 
him, that I had seen many cases quite as bad as his appeared to be, but, notwith- 
standing, I had, by patience and perseverance, succeeded in passing instruments 
and making cures ; and if he would make up his mind to undergo the tedious treat- 
ment, which the nature of his case would inevitably demand, I could, in all proba- 
bility, succeed with him. To this he readily consented, and I commenced the treat- 
ment by directing him to take several warm hip-baths, steam the parts with hot 
water and hops, and rub bear's oil freely into the perinseum, and along the outside of 
the urethra ; injecting, besides, the same kind of oil into the urethra. This he contin- 
ued to do for five days. At the same time, I opened his bowels with castor oil, and 
ordered a light diet. On the evening of the fifth day, I passed with ease, bougie 
No. 4 into the bladder, and allowed it to remain in for two hours, without causing 
any very unpleasant feelings. Upon withdrawing it, a small quantity of urine 
followed. The next day, I passed the same instrument again. The third day, I 



302 TREATMENT OF STRICTURE— CASES. 

passed No. 5, and it was retained for four hours. On the night of the fifth day, I 
introduced the same instrument, and permitted it to remain in all night. On the 
seventh day, I passed No. 7 ; and in this manner I continued to increase the size of 
the instruments, until I could pass No. 13 with perfect freedom. I instructed him 
how to use it himself, and requested him to pass it upon going to bed, and sleep with 
it in all night, two or three times a week. From the first entrance I made into the 
bladder, urine began to flow through its old channel, and five weeks from the com- 
mencement of my treatment, nearly all the urine passed off" in the natural way. In 
eight weeks, it was entirely discharged through the urethra, and the fistulse in the 
perinaeum began to heal up. 

It has now been nearly four years since I first saw this case, and as the gentleman 
has become a resident of this city, I have the opportunity of seeing him frequently, 
and am happy both for myself and for him, that he has quite recovered. 

I am convinced that ninety-nine cases in a hundred, of stricture in the urethra, 
can be cured by judicious treatment, without the use of caustic. I am no advocate 
for the use of escharotics in the treatment of this affection, being well satisfied that 
it almost invariably produces more or less mischief. The Hon. Edward P. Living- 
ston, who was under my care for stricture, and who died from the effects of it, told 
me that he had been laboring under the affection for more than twenty-five years, 
and had been burned with caustic many times, and he declared it to be his strong 
conviction, that from its employment he had been seriously injured. 

I will here take the opportunity to state, that Mr. Livingston not only had a very 
bad stricture in the membranous portion of the urethra, but he also had a great 
enlargement of the prostate gland. After freely fomenting the perinaeum, &c, I 
made three attempts on different days, with the greatest possible caution, in conse- 
quence of his age and infirmities, but could not succeed in passing any instrument 
into the bladder. In fact, the bougie could not find its way into the smallest open- 
ing, but appeared to strike the impediment, as though it were hermetically sealed 
with a very solid material. It is true there was a trifling hemorrhage, caused by the 
point of the instrument, a very common occurrence in bad cases of stricture, but I 
did not make use of force enough to pass a bougie through a boiled turnip. He 
was attacked with chills and fever, and survived but a few days. I have always 
been under the impression that he might have been cured, or at least, had his life 
prolonged some time by an operation through the perinaeum. 



rREATMKNT ok sikh'Tiki;.— 0A8ES B03 



CASE III. 

O. S., aged 41, consulted me May 10, 1846, tor a had stricture in the mem- 
branous portion of the urethra. He had been the mate o( a ship for many years ; 
had had the gonorrhoea many times daring his life, and had seen much hard ser- 
vice ; but in all his sufferings, he declared he had never experienced anything like 
the pain he endured from the stricture. He stated that he had not entirely emptied 
his bladder for several weeks, and that all the water he could make, he was 
obliged to milk away by drops. 

i 

TREATMENT. 

I could not pass any instrument into the bladder at the first attempt, and I there- 
fore ordered him to take several hot hip-baths ; sit over a pail of hot water, and 
nib bear's oil, or lard, freely into the perineeum and along the course of the urethra, 
and to inject into it warm oil. After having done this for two days, I had but very 
little difficulty in passing a small-sized bougie through the stricture. From this 
time I continued to introduce instruments-, gradually enlarging them to the natural 
size of the urethra. At first I let the bougie remain in him from fifteen minute i to 
as much as four or five hours — requested him to sleep with the instrument intro- 
duced all night, and repeat this at least once and sometimes thrice in the week. On 
the last of August, he said that he was as well as ever he had been, and I dis- 
charged him cured, with a recommendation that he should keep a bougie with him 
and continue to introduce it once a fortnight for several weeks, allowing it to remain 
in about one hour each time ; after several months, to pass it occasionally ; and finally, 
leave off the use of it entirely. 

Sometimes this kind of case will return after a length of time — varying very 
much in individuals — from one year to four or five ; and sometimes, they remain 
permanently cured for life. 

During the treatment of strictures, everything relating to the case must be attend- 
ed to. If there is much local inflammation, leeches must be applied and the patient 
treated antiphlogistically. I usually give patients diuretics and mucilaginous drinks. 



304 TREATMENT OF STRICTURE.— CASES. 

Some authors deny that they exert the least benefit. For my own part I am con- 
vinced that they cannot do any harm, and I am very sure that they facilitate the 
cure. 



CASE IV. 



R. R., aged 28, placed himself under my care, October 3, 1844. He had long 
laboured under a difficulty in making water, in consequence of a stricture which he 
supposed was the result of a gonorrhoea. I asked him if he ever had used injec- 
tions, and he said he had not. 

TREATMENT. 

I found an obstruction about two inches from the lips of the urethra, and I expe- 
rienced the greatest difficulty in getting an instrument through it, but finally suc- 
ceeded. I at once introduced a probe-pointed instrument, which I use for such 
purposes, and divided the stricture in three places, in the presence of several physi- 
cians. I then passed in, as in the previous cases, a short piece of bougie, taking 
care td tie a bit of tape to the end of it, both for the purpose of keeping it from 
getting into the urethra and from getting out. I ordered him to remain in his room, 
and only remove the instrument to urinate, for four or five days. This being done, 
he could make as full a stream of water as he ever could. I afterwards passed a 
still larger instrument, a bulbous one I believe, which I requested to be worn four 
or five days longer, when he might take it out and consider himself well. 



CASE V. 



W. S., consulted me for a stricture which had troubled him for a long time, on 
the 19th of September, 1843. This stricture was four inches up the urethra and 
had existed for ten years. He had been under the care of several surgeons, whose 



TRKATMKNT OF STUICTI I," K. CASES. 

treatment consisted chiefly, in dilatation, which gave relief for a few months, when he 

would be obliged to use the boogies again, and so on until lie applied to me. I 
found but very little difficulty in getting a small conical -pointed bougie through the 
stricture, which was an induration or thickening of the mucous membrane and tin- 
subjacent parts, so as to form a kind of ring, closing the passage. 



TREATMENT. 

I divided the stricture as in the preceding case, in three places, without giving, 
scarcely, any pain, and treated it in the same manner — with perfect success. 
I have seen this gentlemen lately, and he informed me, that he as yet had had no 
signs of a return of the stricture, and I feel confident that he never will have any. 



CASE VI. 



Mr. H. W., of this city, aged 50 years, an eminent lawyer, came to me for advice 
June 2, 1842, and stated that he had been punished for his sins about twenty-five 
years. His sufferings arose from an impediment in the urethra, which completely 
prevented the urine from passing out. For many years he had spent from fifteen 
to twenty minutes, and sometimes longer, every time he urinated, and he was 
obliged to milk it away at that. He had consulted several surgeons, but they had 
invariably failed to pass any instrument into the bladder ; and as each operation gave 
him considerable pain, besides alarming him, he had never allowed them to perse- 
vere in " probing" him, as he expressed it. " Perhaps if I had," said he, " they would 
have succeeded in getting something all the way through." 

After hearing his story, I told him that unless he would consent to let me use 
instruments in my own way, and take my own time in doing so, it was not worth 
my time to make any attempt at all. Mis answer was, " there is now no other 
alternative, use your own judgment, and if it is possible, relieve me as soon as you 



can." 



306 TREATMENT OF STRICTURE.— CASES. 



TREATMENT. 

From the account of his case, I expected, of course, to find great difficulty in pas- 
sing the stricture. I first commenced by using a large-sized curved gum bougie, 
which advanced well enough until it reached the membranous portion of the urethra, 
when it made a full stand and satisfied me that it would not pass. I then took the 
next smaller size, and the next, and so on until I came down to the smallest instru- 
ment that could be of any practical use — without meeting with success, drawing 
only a few drops of blood. I then resorted to my usual fomentations and other hot 
applications to the perinseum ; after which, I made another attempt without any 
better success. I now took a steel sound about as large as No. 5, bougie and but 
little curved ; with my left fingers I drew the penis out nearly straight, putting it 
well on the stretch, and at the same time passed the instrument down to the stric- 
ture, and made gradual and firm pressure, which I continued for fifteen minutes, 
when the opposing obstruction gave way, and the sound entered the bladder, and 
out came a full stream of urine the moment the instrument was withdrawn. 

The next day, I had no difficulty whatever in passing a large-sized bougie. I 
came to the conclusion that this obstruction was a kind of drum-head or mem- 
branous curtain, extended across the urethra. This gentleman has since been as 
well as he ever was — now five years, and I believe he will never experience any 
more trouble from it. 



CASE VII. 

L. E., aged 58, consulted me July 12, 1844, and stated that he had been troubled 
in making water for many years, and had neglected to attend to it, thinking that it 
would never amount to anything serious ; the stream which he voided was extremely 
small, and the impediment was situated at the fossa navicularis, and proved to be a 
case very similar to the last, with the exception, that this was a drum-head drawn 
across the lower extremity of the canal instead of the upper. 



TREATMENT OF STRICTURE.— CASKS 807 



Tin: \tmi.\ r. 

I dilated the urethra with a speculum urethras, and was able to see iu the Centre oftbe 
curtain, a very small opening, into which I passed a fine-pointed bougie, and enlarged 
the stricture so that I could introduce the point of a bulbous one, which, by poshing 
on, so broke down or tore away the obstacle that a fall-sized stream of water could 
pass. I ordered the last used instrument to be retained in tin; urethra one or two 
hours every other day, for about two weeks, and the cure has been complete ever 
since. 

This kind of membranous formation, or drum-head as I call it, is very rare ; I 
have never seen more than three or four cases. 

There is no difficulty in curing them ; the only embarrassment occurs, in ascer- 
taining, in the first instance, their precise nature. 



CASE VIII. 

Wm. C, placed himself under my care, July 6, 1847, for a difficulty in making 
water, which had existed about seven months. Upon examining the urethra, I 
found a stricture in the membranous part of the canal, and after several attempts, I 
succeeded in passing a small bougie through the closure. I allowed the instrument 
to remain in the urethra one hour, it producing but very little inconvenience. The 
next day, I passed a size larger quite easily, and kept it in two hours. Two days 
after, I passed a still larger; and in this manner continued to introduce instruments, 
allowing each succeeding one to remain in longer than the last. Finally, I requested 
him to keep it in for five or six hours. Three weeks from the commencement of 
the treatment, I discharged him cured. 



308 TREATMENT OF STRICTURE.— CASES- 



CASE IX. 

E. R., aged 28, a gun-smith, in the full enjoyment of health, and a married man 
of regular and steady habits, sent for me on the morning of the 23d of February, 
1845. When I arrived at his residence, I found him in the greatest distress from a 
retention of urine, which had been brought on from getting his feet wet and taking 
cold. 



TREATMENT. 

I introduced, without much trouble, a catheter of middling size, drew off the urine, 
and left, with a request that he should take a warm bath and drink freely of gum 
arabic water. In the morning of the following day, I was sent for again to repeat 
the operation. His bladder was full, and he was in great pain ; I relieved him in the 
same manner, but with more difficulty than before. This surprised me, as he stated 
that my directions had been strictly complied with, and he assured me that he never, 
previously, had experienced the slighest trouble in urinating. I now ordered him to 
take the following mixture — a table spoonful of it three or four times a day : 

R- Sp : Otberis Nitrici, §ij. 

Tinct. Opii, 3vj. 
Gum. Acacise pulv. ^ij. 
Sacchar. Alb. fj. 
Aquae Distill, f viiss. 

At the same time to take several mustard hip-baths, apply thirty leeches to the peri- 
nseum, to be succeeded by bread and water poultices, and to drink freely of buchu 
tea. 

Notwithstanding all this, I was again sent for about eleven o'clock the subsequent 
evening, and found him writhing in agony with his bladder once more greatly dis- 
tended. I used the catheter, but not without some difficulty, and emptied it for the 
third time. A considerable quantity of blood followed the last drops of urine, accom- 
panied with some pain. 



TREATMENT OF STRICTURE*— casks. 809 

Finding thai this treatment did aol permanently reliere him, I took thirteen ounces 

of blood from the arm ; gave him a large dose of castor <>il ; pushed np the amis a 
suppository, composed of throe grains of opium and one of belladonna ; kept him 
under the nauseating effects of antimony, and requested him to drink copiously of 

the bnchn tea. This had the desired effect. He sent word to me on the fourth 
day that all was right again, though he felt a smarting and soreness about the parts 
when making water. 

This was what I call a truly spasmodic affection of the ejaculatory muscles, and 
nothing else. 

I have been called to fifty similar cases, and if they are not spasmodic, I must 
confess I am at a loss to know what they are. Liston, as well as many other 
authors of equal distinction, deny that there is any such thing as spasmodic stric- 
ture of the urethra. Every writer has a right to express his own opinions. 
Some, certainly, are entitled to more weight than others ; but a knowledge of facts, 
derived from observation repeated again and again, clearly prove to my mind, that 
the urethra is just as liable to be spasmodically contracted as any muscle in the 
body. I however, do not mean to assert that the urethra itself is muscular, but 
merely that it suffers the consequences of spasm from the action of the muscles that 
are appended to it. 



CASE X. 



P. B., aged 26, consulted me October 5, 1846, for a difficulty which he 
experienced in making water, and which had existed for a long time. The stream 
he said was very small, and whenever he urinated, the penis bulged out about an 
inch from the head of it, so that it looked like a hen's-egg. 



TREATMENT. 



Upon making an examination, I found a stricture situated an inch and a half from 
the meatus urinarius, very tough and unyielding to the bougie. I at once divided it, 



'I \ 



310 TREATMENT OF STRICTURE.— CASES. 

which was a circular one, with my probe-pointed knife, in three different places, 
and introduced a short piece of a bougie, as described in the cases already related. 
He wore the instrument for three days ; I then changed it for a full-sized one, and 
requested him to let it remain in five days more — when, I predicted, he would be 
well — and during the time, to keep quiet in his room and live on a light diet. 

I have had three or four cases, in which I was obliged to continue the use of the 
bougie much longer ; but generally, from three to ten days will effect a cure. 



CASE XI. 



OPERATION FOR A NEW URETHRA. 

Since this work was placed in the hands of the printer, I have been called to see 

Mr. , of Lafayette Place, aged 34. The following are the facts of his case : 

Nine months previous to my seeing him, he had contracted a chancre on one of the lips 
of the urethra, which soon degenerated into an ugly phagedenic ulcer, that extended 
up the canal, and was not arrested until it had effected a horizontal division of the 
whole glans, leaving a comparatively thin flap above and below. The prepuce, 
which was very long, by the adhesive inflammation, had been united to the remain- 
ing portions of the glans, forming a kind of phymosis. The passage of the urethra 
had been closed by the same process, and for an inch and a half backwards was 
entirely imperforate. The water had found an outlet on the dorsum of the penis 
near the pubis, and another through a sinus running between the common integu- 
ment and the corpora cavernosa, obtaining an exit at last, through the puckered 
fore-skin. He had a large ulcer on the inside of the left thigh, three on the top of 
the head, and a large prominent node on the forehead. He was much emaciated, 
and so feeble as to be unable to get out of bed. For several months, in consequence 
of pain, he had not slept more than an hour each night. The case, altogether, was 
truly one of the most deplorable description. 



» 
TREATMENT OF STRICTURE.— CASES. ; 51 1 

TREATMENT. 

His penis being much swollen and painful, I directed warm poultices to be dili- 
gently applied to it, and continued them for several days. Internally, he took the 
following prescription : 

R. Sarsaparilluc rad. Ibj. 
Mezerei cort. rad. 5 SS - 
Arctii Lappa), 
Guaiaci lig. aa |ij. 
Serpentarii Virg. *iss. 
Chimaphil. Umb. f ij. 
Aquas, Oxvj. 
Boil down to one gallon of fluid, strain, and add two pounds of refined sugar and one 
quart of alcohol. 

In eight ounces of this decoction, I dissolved one scruple of the acetic extract of 
colchicum and half a drachm of iodide of potassium ; and administered a table 
spoonful at a dose, three times a day. The patient also took, three times a day, 
one grain of the iodide of mercury. 

On the third night after taking the medicine, his pain had left him, and he slept 
without disturbance. 

The inflammation about the penis being reduced, I proceeded to the operation, 
assisted by Dr. Newton, in the presence of several other gentlemen. T excised the 
divided glans and elongated prepuce, as the first step. I next made an incision into 
the urethra, about two inches below the truncated extremity, introduced a trocar 
guarded by a canula, and pushed it from behind forwards, until I had completed an 
opening on the stump. Into the passage I directed a large-sized bougie, and closed 
the wound I had made in the urethra with four sutures. The urethra I kept dilated 
by retaining about four inches of the bougie in the passage, and there fixing it by 
means of + ape. When he had occasion to urinate he removed it, and afterwards 
returned i' to xts place. I prefer using the bougie in this manner to keeping a 
cathete- in bladder ; for I like the plan of washing out the urethra as often as 



312 TREATMENT OF STRICTURE.— CASES. 

convenient, when it can be done without danger of the water passing into the fistu- 
lous passages. The penis was bandaged from behind forwards. The urine now 
flowed as freely through the artificial as ever it had done through the natural canal. 

The swelling of the organ subsided, the incision into the urethra healed without 
suppuration ; while the extremity threw out healthy granulations and soon closed 
over. In less than three weeks from the day of the operation, he left his bed and 
was able to walk about the room as well as ever, feeling only a weakness that was 
consequent upon his long confinement and sufferings. 

I kept him under the influence of the alterative medicines which I a^ first pre- 
scribed, and now he is able to attend to his business as usual, all the syphilitic 
symptoms having rapidly vanished. 



CHAPTER XXV. 

FALSE PASSAGES. 

Definition. — Usual causes. — Where they are most commonly situated. — A peculiar condition of the 
mucous membrane may favor them. — Differences in instruments. — The operator often in fault. — 
The proper way to pass the instrument. — Difficulties of knowing when a false passage exists. — 
Necessity of caution. — The porte-empreinte for taking a cast of the part. — Further directions for 
proceeding. — No certain signs to distinguish a false passage — pain, hemorrhage. — Experience 
useful. — The treatment : catheter sometimes necessary. — Puncture of the bladder. 

A false passage i san accident which usually happens to the urethra from intro- 
ducing instruments into the bladder. They nearly always occur, in consequence of 
a stricture or enlarged prostate, and are generally produced, by forcing the catheter 
or sound out of the natural channel into the surrounding substance. It is said by 
Amussat, that they also may be occasioned by improperly applied cauterization. 
This statement may be correct, but I have never met with any fact which could lead 
me to believe that such a result takes place from the use of the cautery. 

As strictures are most common at the beginning of the membranous portion of 
the urethra, immediately behind the bulb, so it is at this situation that false passages 
are most frequently found. The shape of the canal may, however, exert some influ- 
ence in the production of such casualties at this particular spot. There is, however, 
no part of the urethra in which they are not, occasionally, to be seen. In the pros- 
tatic portion, they are by no means uncommon. 

False passages are, oftener than elsewhere, made in the inferior arc of the canal ; 
but there is no part of the circumference exempt from them. There is every con* 

313 



314 FALSE PASSAGES. 

ceivable variety in the circumstances attending them — in their size, extent, and 
place of termination. Generally they end in a cul-dc-sac, somewhere in the spongy 
tissues, but they are sometimes known to extend to the bladder or rectum. 

It is probable that the formation of false passages is favored by a peculiar con- 
dition of the mucous membrane, as well as by stricture. No doubt pathological 
changes may render the membrane lining the canal so soft, as to be very easily la- 
cerated, and that it is, therefore, when in such a state, more readily broken and pene- 
trated, than when it is more healthy or differently affected. Instruments, also, have 
some influence on the tendency to false passages. Those of f he metallic kind, 
which are stiff and inelastic, and those that are small or sharp-pointed, are the most 
dangerous ; while such as are soft and flexible, and of considerable size, very rarely 
do injury. 

A common source of the mischief, is the hand of the operator. If the instrument 
be pushed forward too rapidly, and with force, when it reaches the point of obstruc- 
tion, or the natural curve of the urethra, it may be plunged through the membrane 
into the part beneath, before the surgeon is aware of any accident. He perceives 
that the instrument advances no further, but he knows not that injury has been 
inflicted, until, perhaps, he is apprised of it by a considerable effusion of blood. A 
want of anatomical knowledge, necessarily increases the difficulty of introducing the 
bougie, and is not unfrequently a source of accident, which, otherwise, would be 
a\jided. 

To pass the instrument in a manner most favorable to safety and success, the 
surgeon should hold it short, by which he obtains more control over its movements, 
and instantly becomes sensible of any obstacle that opposes its entrance. There is 
one thing that may embarrass even those of experience : when the bougie meets 
with an obstruction, it is not always easy to decide whether it is arrested by a stric- 
ture, by a false passage already existing, or by some of the natural difficulties of the 
urethra. At the bend this may especially be the case. If the patient has never 
been subjected to catheterism, we may rationally conclude that there is no false 
passage ; but, should the history of the case be otherwise, then our judgment, guided 
by the most careful manipulations, will, perhaps, be able to decide correctly. It is 
obvious that great caution is demanded, for, by rashness, instead of penetrating the 
stricture, we are liable to break open a new passage, and do much injury to the 
patient. 



FALSE PASSAGES, 815 

The porte-empreinte, of which 1 have spoken and given .1 representation in the 

Chapter on Strictures, will greatly aid us, in these cases, in making an exploration. 
Should there be a stricture and false passage, or stricture alone, or neither the one 
nor the other, but a free channel, by properly using this model bougie, it will pro- 
bably advise us of the fact. Doubt is now dissipated. Having obtained a cast of 
the urethra, we know exactly what we have got to encounter, and, possessed of the 
proper skill, we may proceed with a strong feeling of confidence. 

The penis should be drawn upon the instrument, by which operation, the canal is 
straitened out ; and, if there should be any plicae, or irregularities in it of any kind, 
or if there be follicular openings, or false passages, we shall, in this manner, either 
diminish or entirely remove them. It is important to have an idea of the situation 
of the beak of the instrument as it advances towards the bladder, so that we may 
depress the handle and manoeuvre properly to keep it in the axis of the urethra. 
When it has arrived at the prostatic portion, and an obstacle presents, the finger 
passed into the rectum, may be made to afford essential assistance, by elevating it 
so far that it will, probably, glide over the gland, and slip at once into the bladder. 

It must be confessed, notwithstanding, that there is much difficulty, at times, in 
deciding upon the existence of a false passage. It may be supposed, that, when the 
urethra is torn, there will be considerable pain, and certain sensations, such as tear- 
ing, or pricking, to warn us of the accident. These sensations are not to be impli- 
citly relied on, as they may occur when the bougie is engaged with the stricture, or 
they may be absent when we have made extensive lacerations. The general irrita- 
bility of the urethra may be such, that intense agony is felt merely on passing an 
instrument, when no particular obstruction is encountered. If pain be accepted as 
a certain sign, when such sensibility exists we should receive an erroneous impres- 
sion. On the other hand, we might go confidently forward, the patient making but 
little complaint, while the bougie is rending the tissues before it ; and, as it has some- 
times happened to others, the first knowledge we have that a false passage has been 
made, is the unexpected appearance of the point of the instrument beneath the skin, 
far from the track of the urethra. It might be supposed that the resistance made 
by the sound part, would admonish us that the instrument had taken a wrong direc- 
tion. This i3 not the fact. The natural tissues yield more readily, oftentimes, than 
a stricture ; and the bougie, once in a false passage, will, perhaps, cause less dis- 
tress, than if it be kept in a strictured part. 



316 FALSE PASSAGES. 

It is evident from what has been said, that to determine the presence of false pas- 
sages is no easy matter ; and that much judgment may be required to arrive at a 
correct conclusion. Experience will do much in resolving doubts ; it sharpens the 
perceptions, and enables us to appreciate apparent trifles, and weigh circumstances, 
that would otherwise pass unobserved. We have already remarked, that the porte- 
empreinte will lend us much assistance ; but, it must be admitted, that, useful as it 
is, like all the other sources of diagnosis, it may nevertheless fail. 

But, happily, we do not always meet with this perplexity in ascertaining the exist- 
ence of a false passage. Knowing that we have got one or more to deal with, how 
are they to be considered and treated 1 

Fortunately, under ordinary circumstances, a false passage is an accident from 
which no serious consequences need be apprehended. If the patient is able to 
empty his bladder through the natural channel, it is manifest that there is no urgent 
necessity for surgical interference. The urethra should then be allowed to repose, 
and in a few days, we may expect that nature will have closed the wound that mis- 
directed art had opened. The more especially is such a result to be anticipated, if 
the passage has been made with a small-sized instrument, when the injury has the 
character of a puncture rather than that of a laceration, and will, from the first, 
exclude the urine more effectually, and favor the tendency to heal without suppura- 
tion. The direction of the passage, even when large, is propitious to a ready cica- 
trization, because, when water is passed, and the walls of the urethra thus distended, 
the orifice of the wound is inclined to be pressed together; which circumstance, will, 
perhaps, prevent the entrance of the urine, that would prove, were it freely admitted, a 
constant cause of severe irritation, and might greatly delay the healing process. If 
there be much accompanying inflammation, the case is to be treated upon the usual 
antiphlogistic plan, both locally and generally ; and nothing should be omitted, which 
can assist in subduing this condition. When the rupture of the mucous membrane 
is so extensive, that water cannot be made, without aggravating the diseased condi- 
tion, it becomes extremely desirable to introduce the catheter, and, by this means, 
empty the bladder. 

These remarks rest on the assumption, that the false passage is external to a stric- 
ture. If the reverse of this be the fact, and there exist an opening in the urethra 
between the stricture and the bladder, however it may have been originally induced, 
the difficulties are much multiplied ; and we may expect infiltration of urine, sinuses 



TREATMENT OF STRICTURE.— CASKS. 31 T 

or fistula?, or all combined. In this case, it becomes a matter of pressing moment 
to pass the stricture, and reach the bladder with a catheter, that we may avert the 
danger, or arrest the progress of those consecutive occurrences which may so readily 
take place. When there is complete retention of urine, and it is found impossible 
to introduce instruments by the usual means, it remains for the surgeon to determine 
upon the plan most advisable to be adopted in such an emergency. If there is 
reason to believe that the false passage, if continued, would reach the bladder, and 
that it already has advanced nearly to that viscus, it may be a question, whether it 
would not be the easiest, and, for the patient, the best method of affording relief, to 
force an instrument onward, and thus convert an embarrassing accident into a sur- 
gical operation. The other mode of meeting such a casualty, is by puncturing the 
bladder, cither above the pubis or through the rectum,. as I have described in the 
Chapter on Stricture. 









CHAPTER XXVI. 

- 
INFILTRATION OF URINE, ABSCESS AND FISTULiE. 

Consequences of G-onorrhcea and Stricture. — The immediate causes of infiltration : stricture; ramol- 
lissement ; rupture of the urethra. — Symptoms : swelling in the perinaeum ; the scrotum or penis ; 
intense pain ; inflammation ; rigors ; fever ; great debility ; pulse intermitting ; hiccough ; delirium ; 
death. — Gangrene. — treatment : incisions ; support the constitution by tonics. — Fistula sucoeed 
the above. — Diagnosis. — treatment : by dilating the stricture ; the use of caustic. — Blind fistulae to 
be opened with the lancet. 

Infiltration of urine and abscess, are accidents that frequently follow gonorrhoea, 
sometimes without stricture, but most commonly with it. 

The immediate cause of Infiltration, is a rupture of the walls of the urethra, which 
may be occasioned by a softening, or ramollissement of the mucous membrane, from 
the effects of inflammation, or from an obstruction to the free passage of urine. If 
a stricture exists, there is always considerable pressure behind it, from the forcing 
efforts of the bladder to empty itself. A pouch in the urethra is formed, sometimes, 
of great extent, in which the water is retained, in greater or less quantity, after the 
bladder has ceased to contract in the act of evacuating its contents. In this situa- 
tion it is a source of irritation, and may cause an ulcerative inflammation ; or, by 
stretching the mucous membrane to a great degree, this tissue may become so thin, 
that, finally, it gives way, and the water passes through. The urine will also escape, 
occasionally, by transudation, when the membrane is thin and soft, and there is 
much pressure. 

These are the most common causes of infiltration. It now and then occurs from 

318 



INFILTRATION OK UK I NK.— SYMPTOMS. 819 

abscess, arising from external injuries, or from unknown causes of inflammation in 
the deep-seated tissues of the perineum. Hut abscesses are oftener the conse- 
quence, than the cause of infiltration. 

Symptoms. — In straining to make water, when there is a stricture, the patient 
feels a sadden relief, although no urine, or only a small quantity passes through tin- 
urethra. There is no longer any expulsive effort made, and the irritation subsiding, 
the spasm of the stricture relaxes, and water can now be made the natural way. A 
period of temporary ease is enjoyed, but this period is only a lull. A new train of 
symptoms soon display themselves. A swelling in the perina3um, the scrotum or the 
penis, is the first circumstance that developes itself, accompanied with intense pain. 
The water has been diffused in the cellular tissue, and a violent inflammation imme- 
diately ensues, the more intense from the highly acrid nature of the fluid, which has 
been effused. When the urine is long retained in the bladder, it becomes doubly 
irritating, as the watery parts are partially absorbed — leaving behind the saline par- 
ticles, with which it is impregnated. The constitution sympathizes with the local 
disease. The pulse becomes excited ; it is full and hard, preceded by chilliness. 
This condition is succeeded by other symptoms of the typhoid kind. The pulse 
becomes feeble, irregular, and intermitting ; the tongue is dry and cracked ; the 
strength is wonderfully impaired ; and the countenance is changed, and has a 
remarkably haggard and heavy look. The skin is cold and clammy, the patient is 
distressed by hiccough, which can only be relieved for a few minutes at a time. 
These symptoms are followed by low muttering delirium, coma, and death. 

The appearance of the parts affected, assume a dark livid color, and are speckled 
with black spots, that increase in size, showing the presence of gangrene, and they 
become detached as large sloughs, leaving the muscles, aponeuroses, and bones, ex- 
posed. If a black spot is seen on the glans penis, it is a sign that the whole of the 
corpus spongiosum is infiltrated with urine. The process of mortification, sometimes, 
is frightfully extensive. The skin of the penis, the scrotum, the perinseum, and the 
lower part of the abdomen, have all been seen destroyed, exhibiting a huge ulcer 
actually appalling to behold, with the denuded testes hanging supported by their 
cords alone. 

The common course which the urine takes, is towards the root of the penis, 
thence to the perinseum, the scrotum, and the body of the penis. Wherever the 



320 INFILTRATION OF URINE. — TREATMENT. 

rupture occurs, it does not appear, that there is much difference in the direction of 
the urine. The chief modifying circumstances, are the extent of the opening in the 
urethra, and the rapidity with which the infiltration takes place, 

The symptoms, as we have above described them, are not always present, for if 
the water escaping into the cellular tissue be small in quantity, or, if there be 
timely scarifications, before the death of the parts ensue, so that the water can pass 
off through the integuments, the most fearful of the symptoms will be averted. 

Suppose the urine escapes into the cellular membrane, either by transudation, or 
through a very small rupture. The patient will complain of slight shivering, and he 
may have a little reaction. In the perinseum there is a sense of fullness, which gra- 
dually increases, until a tumor, perhaps, maybe distinguished in the part, surrounded 
with some cedematous effusion, especially in the scrotum. The skin becomes 
inflamed, and we are able to detect fluctuation of fluid, as if an abscess had formed 
beneath. This abscess, possibly, may burst into the urethra or rectum, or, if left to 
itself, will open exteriorly. 



TREATMENT. 

.■ ' 



When we are aware that urine is infiltrared in the cellular tissue, no time is to be 
wasted, as the accident is liable to increase rapidly, and the deplorable effects already 
described, may complicate the case. The tissues must be at once separated, to give 
a ready exit to the water. The number, direction, and depth of the incisions, will 
depend upon the character and extent of the infiltration. The surgeon should not 
be satisfied, until he completely attains the end for which the cutting is done. If the 
infiltration be slight, but an abscess formed, it is important, in like manner, to open 
it with an instrument, and thus prevent the ulceration of the tissues, and the empty- 
ing of the abscess, by a natural operation. After such an opening, there will be a 
discharge of pus ; and the urine will also be observed to pass through this outlet. 
The oedema of the neighboring parts now subsides, and by proper management, we 
may succeed, even in the worst of cases, in repairing much of the mischief which has 
been done. It is of paramount importance, to sustain the powers of the system ; 
and tonics, such as cinchona or quinine, are especially indicated, when there is mor- 
tification, to support the constitution, and enable it to throw off the sloughs. 



FALSK PASSAGES/— TREATMENT. 321 



fistula:. 



Infiltration and abscess will frequently leave behind a fistulous opening} but it 
is by no means, usually, a difficult matter to cure it. These fistula- may have 
several external openings, but they very rarely have more than one when they open 
internally, which may be either in the bladder or urethra. It is unnecessary to 
speak of the primary cause of these passages ; for what we have said of the pre- 
ceding affections, will fully apply to this, — the cause being one link further off in 
the chain of morbid actions. 

There are two varieties of fistulas : the first opens externally, and is complete ; 
the second, has only the internal opening, and may be compared to the hi i ml fistula 
of the rectum. 

They sometimes terminate in the rectum ; sometimes, in the pubic region ; at 
others, in the groin, the thigh, the dorsum of the penis ; but generally, they end in 
the perinseum. 

When an ordinary fistula opens either in the perinseum, or in the penis, or in any 
other situation near to the internal opening, the diagnosis is not difficult. Whenever 
water is made, a small quantity of it flows drop by drop through the fistula, and may 
be recognized by a peculiar urinous odor. But if the passage be of considerable 
extent, and if but a very small quantity of water pass into the opening, the diagnosis 
is rendered more obscure, because the only discharge is a kind of serum, destitute 
of the characteristic smell of urine. 

The fistulous passage, along which the urine flows, is, in time, lined with a pseudo- 
mucous membrane, which, in obedience to the law of the economy, accommodates 
itself to the function that has been assigned for its performance. When the fistula 
has long existed, the neighboring parts become hardened, and the external orifice 
is commonly covered with pale-colored fungi, with the borders projecting and everted. 

Urinary fistulee give to patients the greatest annoyance, from the discharge which 
always occurs when they make water ; and they are particularly disagreeable, when 
they are large, and the quantity of water considerable. 

TREATMENT. 

If the fistula be large, it is more difficult to heal than when small ; but in any 
case, no great deal of skill is required to effect a cure. So long as urine continues 



322 FALSE PASSAGES. — TREATMENT. 

to pass through the passage, that long will the fistula remain open. It is hence 
manifest, that the primary indication is to re-establish the channel through the urethra. 
This is to be done by removing the stricture. A small catheter may be used for 
drawing off the water, but it does not perhaps facilitate the cure, although it may 
afford more immediate relief. The best plan, I believe, is to commence the treat- 
ment by dilitation ; and it will be found, that so soon as the urine begins to pass readily 
through its natural canal, the fistulous opening will show a disposition to close. In 
a month's time, this measure alone will, oftentimes, complete the cure. There are 
other cases that may prove more intractable, and several months, or even a year, 
will scarcely be sufficiently long to effect the purpose we have in view. This part of 
the treatment, being the same as that recommended for the cure of stricture, it is 
unnecessary here to add more. 

In aid of the bougie, (or, what some prefer, the sound,) the bottom of the sinus 
may be touched once in three or four days, with the nitrate of silver. This increases 
the tendency to heal. It may happen that the external opening will be inclined to 
heal more rapidly, than the internal one. This must be prevented, as, should the 
superficial parts close up, prematurely, the case will be reduced again to that of an 
abscess, and there will be another discharge of pus. To obviate this accident, while 
the deep parts of the fistula are stimulated with the lunar caustic, the orifice should 
be lightly touched, once in a week or ten days, with the potassa fusa, which will 
prevent the accident that I have spoken of. By pursuing this plan, we shall always 
succeed in healing a complete fistula. 

There is, however, to be noticed, the blind fistula, that requires a treatment in 
some respects different. When we meet with a tumor in the perinaeum, without any 
external opening, it is to be opened with a lancet, and thus converted into a fistula 
of the common kind. The subsequent treatment, is the same as already recom- 
mended. 

It may occur that the tumor in the perinseum is very small, showing that the 
quantity of urine that enters it is comparatively trifling. When water is made, a 
little passes into it, and afterwards escapes from the sac that exists, by regurgitation. 
The disease, consequently, does not advance, aud yet it cannot subside. This state 
of things may continue for years, without much change. The first thing to be done 
in this case, as in the preceding, is to pass a lancet into it, placing in the wound, 
afterwards, a little lint, to prevent it from healing by the first intention. After three 
or four days, the lint may be removed. We now observe, if, when the patient voids 



FALSE TASSACES.— TREATMENT. 



323 



his urine, any of it passes through the opening ; should this be so, the treatment 
is simply that previously indicated. If otherwise, and no urine (lows, u piece of 
caustic potassa may be introduced through the wound, to the tumor, so as to cause 
a considerable slough. A portion of the tumor being thus destroyed, when the 
slough has come away it is probable that the case will now have become an ordi- 
nary fistula, and is to be treated accordingly. 



CHAPTER XXVII. 



HYDROCELE. 



Definition. — Causes. — Symptoms. — Diagnosis. — Scirrhous testicle. — Treatment. — Divided into 
palliative and radical : tapping; trocar; needles; injections into the cavity — the different kinds — 
effects. — Accidents which may result from carelessness. — Treatment by electro-galvanism. 

This affection, an accumulation of serum within the tunica vaginalis testis, is a 
very common disease, and may be traced to many different causes. There are other 
effusions giving rise to the same general appearances, and that have been character- 
ized by the same common name, but they constitute, properly, other and quite dis- 
tinct maladies. 

The more frequent remote causes of hydrocele, are injuries done to the testicle, 
as from a blow, or bruise from a saddle, which excites severe inflammation. This 
subsiding, the parts are left relaxed and debilitated, and it is found that a gradual 
enlargement of the scrotum is taking place, from a slow effusion from the serous 
coat. This may occur in consequence of excessive activity in the exhalents, or 
diminished activity in the absorbents, or from a combination of these two conditions 
existing at one and the same time. In short, the ordinary pathological state of 
dropsy in any other part of the body, when present in this situation, is competent to 
give rise to all the symptoms of hydrocele. It frequently is brought on by a thicken- 
ing of the coats investing the testis, and not seldom it is dependent upon a disease 
of the urethra. I have known it to be traced by patients to long protracted venereal 
excitement, or to retention of urine painfully continued. It may, in a word, be laid 

324 



HYDROCELE. 

down, thai whatever is capable of producing intense excitement in the testicle, or in 

its appendages, leaving as it subsides a correspondent degree of debility, is a suffi- 
cient cause of hydrocele. 

This form of the disease may sometimes be mistaken for collections of water, 
which gathor in cysts, derived from unobliterated portions of the peritoneum that 
accompany the cord. Sometimes, the two forms of disease co-exist. 

In all these cases there is great enlargement, and frequently the distention is 
really enormous — several pints of lluid having accumulated within the sac. 

The various external layers become thickened, but there is very little, if any 
pain. The serum is not always of uniform color or consistence. Generally it is 
straw-colored, like other serous effusions, and contains albumen — at other times it 
is dark and thick. 

The shape of the swelling is peculiar ; as it increases, it assumes a kind of pyra- 
midal form, and in some degree resembles a large pear. The enlargement occurs 
in front of the vessels of the cord. This shape is produced by the cremaster muscle, 
which is connected to the cord by cellular membrane, and embraces the serous 
coat. 

Hydrocele may, in most cases, be readily distinguished from the other affections 
of the same organs, which give rise to appearances somewhat similar. It is gen- 
erally smooth, of a definite figure, and is somewhat transparent. There is a par- 
ticular glossy surface ; when it is large, fluctuation may be easily perceived, and on 
examining the top, the curd is felt loose and unencumbered, showing clearly that the 
case is not one of hernia. 

Such are the more common signs by which we determine the existence of hydro- 
cele. But these are not always present, and then the diagnosis becomes somewhat 
difficult, and we are obliged to determine by other evidence. 

If the apex of the tumor extend into the inguinal ring, we may reasonably suspect 
a hernia. We therefore inquire into its history. The swelling from rupture begins 
above, and descends by degrees ; that from effusion, commences below, and rises 
upward. This knowledge we must obtain from the patient. If the patient be 
placed upon his back, the tumor grasped, and neither position nor pressure cause 
any change in it; if he be now requested to rise and cough, and if there be no dis- 
tinct shock given to it from the agitation created in the abdominal cavity, then it is 
quite certain that the case is not hernia. 



326 HYDROCELE. — TREATMENT- 

In scirrhous testicle, water is often collected between its coats, and it may be 
mistaken for hydrocele. The weight, and the pain occasioned by handling it, and 
other circumstances which point to a more formidable disease, will generally enable 
us to distinguish between them. 

There is a species of enlarged testicle, offering so strongly the feeling of hydro- 
cele, that it has often been mistaken for it. It is what is called the scrofulous testis. 
To the sense of touch it presents an elasticity precisely like that of a fluid. It is a 
soft enlargement. 

These instances, in which there occasionally is difficulty in deciding upon their 
nature, warn us of the importance of fully considering all the facts pertaining to each 
particular case, previous to operating ; although, at the first view, it may appear to 
be of very easy diagnosis. 

It will be inferred from what has been said of the cause of hydrocele, that the 
tumor is not always merely an effusion of water. It is sometimes accompanied with 
an enlarged testicle — in which case, there may be disease of both the testis and its 
tunics. This condition, when the quantity of serum is very great, we may be unable 
to detect ; but at other times, when the quantity is more moderate, it can be ascer- 
tained by the sense of hardness at the posterior part, where the testicle is nearly 
always situated. 

Occasionally it will be found, that this organ, so ^ ov from having increased in size, 
is actually smaller than when in health. 

In speaking of the exciting causes of hydrocele, it is important to observe the 
close relation existing between the urethra and the organs enveloped by the scrotum. 
It often happens that an irritation in this part, brings on morbid action in the testicle, 
and thus becomes the primary cause of the disease we have under consideration. 
To effect a radical cure, therefore, it is essential, if this fact be present, to ascertain 
it, and comprehend it in our general plan of treatment. 

TREATMENT. 

This may be divided into that which is palliative, and that which shall effect a 
permanent cure. The one is intended to remove the prominent symptom from which 
the affection derives its name, and the other, to remove the cause which produced it. 




u\ DROCELE.— THE a tmia i 

The palliative consists id evacuating the water. This is done most readily by means 
of the trocar and canula. The operation is performed by embracing the swelling with 
the left hand at its posterior part, putting the skin 
tightly on the stretch, while the trocar in the other 
hand, is entered at right angles with the tumor, at 
that part which is most prominent, and a little below 
the point which is midway between the neck and 
base. [>'" cut.] The puncture should be done with 
firm and steady pressure, and not by plunging, as 
has sometimes been recommended. When the 
canula has quite penetrated within the tunica vagi- 
nalis, which will be known by the ease with which it 
advances, the direction is slightly altered, to avoid 
injuring the testicle, that probably lies directly behind 
it. The handle must be depressed, carrying the point more upward, as is shown in 
the following cut ; the canula now should be thrust forward with the thumb, drawing 
at the same moment the stilet backwards. As soon as the cavity is emptied, to 
accomplish which, entirely, it is necessary gently to squeeze the sac and raise it 
from the bottom, the canula is to be withdrawn, and the part supported by a sus- 
pensory bandage. 

A lancet pointed trocar is sometimes used for tapping, covered with a spring 
canula ; and when the object is merely to afford temporary relief, this is perhaps 
better than the ordinary round one ; but if a fluid is to be injected afterwards, then 
it should be set aside as unsuitable. 

Another method has lately been practised, and with equally satisfactory results. 
Instead of puncturing with the trocar, a common needle may be used of middling 
size, (a sharp-pointed darning-needle is the best,) which is introduced in several 
places, from each of which, a drop or two of fluid makes its appearance externally. 
Internally the opening continues longer unclosed, and the contents of the vaginal 
tunic gradually oozes into the cellular tissue between the coats, causing, in this way, 
an anasarca of the scrotum, instead of a proper hydrocele ; and the Quid, which has 
changed its situation, is ultimately removed by absorption. This operation, which 
is very simple, may often be repeated. As the quantity of water is diminished, 
increased caution is required in making the punctures, lest injury be done to the tes- 



328 HYDROCELE. — TREATMENT. 

tide, which has approached nearer to its surrounding membrane. Sometimes, in 
this manner, a perfect cure may be accomplished — but it is not to be confidently 
relied on ; for frequently it occurs, that the effusion will continue and the tumor 
be reproduced as in the first instance. There is nothing to recommend it, except the 
ease with which it may be done, and the greater readiness with which timid patients 
submit to it, than to the use of a larger instrument. 

To effect a permanent cure, the mode of procedure is the same as that already 
described, with the trocar and canula, but we must provide ourselves, also, with a small 
gum-elastic bottle, having a nozzle fitted to the canula, and made complete with a 
stop-cock. Some surgeons think a bladder better, as there is less liability to inject 
air with it. We should have ready for use, at the same time, the fluid that is to be 
employed as an injection. Various kinds of injections are used; but as the chief object 
is to produce a mild inflammation of the serous membrane, any moderately stimu- 
lating fluid will perhaps answer the purpose. Wine and water has long been popu- 
lar — three-parts of the wine to one of water ; cold water alone ; a solution of sul- 
phate of zinc ; pure port wine ; a solution of iodine. &c. If the astringent salt be 
used, we should dissolve a drachm of zinc, in sixteen ounces of water. Mr. Liston,* 
the great London surgeon, prefers strong port wine to anything else ; Mr. Velpeau, 
the great Paris surgeon, is accustomed to employ injections of iodine ; and the 
success of his practice has caused it to be generally adopted in France. The 
strength of wine being variable, it is, on this account, less to be relied on than on 
those injections, the strength of which we can accurately regulate. Whatever be 
used, however, the effects are to be looked to after the injection has been made. 
Sometimes, the strongest gives very little uneasiness ; in other instances, it produces 
much pain and great irritation. We, therefore, cannot exactly decide in advance, 
the strength we may require to complete the cure. 

About four ounces of fluid is the proper quantity to inject at one time. It should 
be permitted to remain in the sac from two to five minutes ; or, if there be much un- 
easiness, for a shorter space, when it may be allowed to escape, and a fresh injec- 
tion is to be used. We conjecture that we have done enough to attain the object in 
view, when the patient complains loudly of the irritation or pain. The cavity is next 
to be evacuated completely, the surfaces pressed gently against each other, and the 

* While this work is going through the press, science has been called to lament his death. 



HYDROCELE.— TREATMENT. 



129 



canula removed. It has been found necessary by Mr. Litton, in casts in which there 
was an unusual degree of insensibility, to resort to the undiluted ardent spirits, such 
as common whiskey, and with the best result. 

The effects of this operation is a high inflammation in the tunica vaginalis, a 
swelling of the testicle, and a slight redness of the scrotum. So great and rapid is 
the enlargement of the whole tumor, that it might be supposed the hydrocele had 
returned, and was of a worse kind than in the first instance. Effusion of colored 
serum into the cavity, and serosity into the cellular tissue uniting the different in- 
vesting coats, accompanied with pain in the parts and shooting back into the loins, 
very soon ensue after the injection has been made. Coagulable lymph is thrown 
out, the walls of the serous membrane become in the end agglutinated together, and 
the cavity obliterated. The fluid which may happen to remain in the sac gradually 
is absorbed, and an equal action is established between the exhaling and absorbing 
processes. 

Easy as is the performance of this operation, yet by carelessness, or gross igno- 
rance, it may sometimes be accompanied with the most serious consequences. It 
should always be ascertained by the surgeon, previous to injecting the fluid, that not 
only is the point of the canula, but also the opening near its 
extremity, fairly introduced within the cavity. During the 
manipulations, the tunica vaginalis may become detached 
from the membrane surrounding it, as shown in the cut, and 
the probabilities are then increased, that the irritating injec- 
tions may reach a wrong destination, by being forced into 
the cellular tissue, into which it most readily enters. Such 
an accident will be followed by violent inflammation of the 
scrotum, fever, pain along the cord, in the loins, and some- 
times by extensive suppuration and sloughing. This mis- 
fortune has befallen even the most eminent and accomplished surgeons, but it ought 
not, and, assuredly with the patient, will not be received as a good excuse, when 
it happens in less experienced hands. Caution may always prevent it; and if profes- 
sional reputation be worth a surgeon's solicitude, he will, in all cases, be perfectly 
certain, as he proceeds with the operation, that no such mishap can reasonably be 
laid at his dooi. 

There is another method of curing hydrocele, that has been tried in Paris with 




330 CONGENITAL HYDROCELE. 

success, but we cannot perceive that it possesses any substantial advantages over the 
modes already detailed. For this purpose, galvanic electricity has been employed. 
Two sharp needles, one connected by a wire to either pole of a common-sized 
battery, have their points introduced into the cavity of the tumor, at opposite sides. 
The machine is now set in action, and a current of electricity is conducted by this 
means through the hydrocele. Much pain is experienced, probably from the heat 
generated in the needles, by the great amount of electric fluid which traverses them. 
After the galvanic action has been continued for half an hour, the operation may 
cease until the following day. It will be perceived very soon, that the tumor is di- 
minishing rapidly in size ; and a few days have been found long enough to perfect a 
radical cure. This way of removing hydrocele, has not been repeated sufficiently 
often to establish its character. Although I have said, that, substantially, it may be 
no better than the operation by injection, it is, notwithstanding, less formidable to the 
imagination of timid patients ; it is exceedingly easy to do ; it does not appear to be 
followed by any painful inflammation, which is essential to the tapping and injecting 
operation, and there is no danger of such accidents as I have described. 

After the operation for hydrocele, it will generally be sufficient for the patient to 
confine himself to his room ; but, should the inflammation become violent, it will then 
become necessary to put him to bed, and treat him upon the usual antiphlogistic plan, 
with poultices, leeches, purgatives ; and, if the case be one of particular severity, with 
nauseating doses of tartrate of antimony, and such other remedies as the necessity 
of circumstances suggests. 

There are other effusions besides that just described, that are sometimes met with, 
and that are known as varieties of hydrocele. They are dependent on causes dif- 
ferent from those producing a fluid within the tunica vaginalis testis. I shall merely 
notice such as are the most important. 

CONGENITAL HYDROCELE. 

This is an accumulation of fluid within the tunica vaginalis, which occurs before 
the communication between the abdomen and the sac enclosing the testicle is closed. 
The swelling is sometimes considerable, particularly when the patient is in the up- 
right posture ; and it is of an oblong shape. Being surrounded by water, the testis 
cannot be readily felt, but the spermatic cord may generally be perceived situated 
behind, and inclined towards the outer side of the superior part of the tumor. 



HYDROCELE OF THE CORD I II 

By pressing the swelling, the water gradually is forced into ih<> abdomen; ii ma 
however, be observed, thai in every case, this displacement of the fluid is sol readily 
effected — and it may require some management and patience. The circumstan 

thai we have just related, is conclusive in making a diagnosis. Ii may be added, 
that the tumor is almost always translucent. 

TREATMENT. 

If there happen to be a congenital hernia complicated with hydrocele, the first 
thing to be done is to return the intestine to the abdomen. Methodical compression 
made upon the ring, together with topical applications, are generally resorted to, and 
in most instances, will be sufficient to effect a cure. I have in several cases, perma- 
nently removed the affection, by simply tapping and drawing off the water. Injec- 
tions are universally condemned, as there is danger that the fluid may pass into the 
cavity of the abdomen, and produce a fatal peritonitis. 

We sometimes meet with hydrocele of the cord, which is constituted either 
by infiltration throughout the cellular tissue of the cord, or by an accumulation of 
water in cysts. Hence this description of hydrocele is divided into two varieties. 

Hydrocele from Infiltration, is, in fact, a collection of serum in small cells, involv- 
ing, sometimes, the whole extent of the cord, from the epididymis to the inguinal 
ring ; at other times, only a part of this organ is implicated, either downwards or 
upwards. The tumor or swelling gives the idea of a soft thick cord ; it is without 
pain, or any external signs of inflammation. 

This form of hydrocele is scarcely ever troublesome to the patient; and unless it 
acquires a considerable volume, which is very rare, it may even escape the observa- 
tion of the patient himself. 

Treatment. — So long as the affection produces no inconvenience, it is advisable 
to do nothing. When, however, it becomes large, and shows a disposition to inflam- 
matory action, it may be necessary to have recourse to the aids that surgery can 
afford. Palliative treatment is utterly useless. What we do must contemplate a 
radical cure. The only operation that has been found of service, is that of incision. 
This operation is more serious and difficult than that performed for vaginal hydro- 
cele, as the wound is much greater, and there is danger of injuring the vas deferens, 
as well as the spermatic veins and arteries. The whole of the tumor must be laid 



332 HYDROCELE OF THE CORD. 

open, and the water liberated from all the infiltrate^ cells, by making moderate pres- 
sure. The wound is now to be filled up with a pledget of lint, and layers of linen 
and compresses are to be applied over the whole. When suppuration is established, 
the lips of the wound may be approximated, by employing strips of adhesive plaster. 

The general treatment, if any be required, is the same as that which is indicated 
for wounds in any other part of the body. 

Encysted Hydrocele, frequently succeeds to the affection last described. Some 
of the little cells containing fluid, may become gradually distended, until they have 
attained such a size, that they constitute cysts of considerable magnitude. There 
may be but one of these cystic tumors, or there may be several. It is not difficult, 
usually, to distinguish this from other affections of the cord, but it may be mistaken 
for a supernumerary testicle. 

This affection nearly always has a very slow progress. Rarely is it seen larger 
than a hen's egg, and it gives very little annoyance to the patient. The treatment is 
the same as that recommended for hydrocele of the tunica vaginalis — by penetrating 
into the cavity of the cyst, and treating with injections of a stimulating character. 



CHAPTER XXVIII. 

CIRCOCELE: VARICOCELE. 

Description. — Symptoms. — Causes. — May be mistaken for omental hernia. — The diagnosis. — 
Treatment : local bleeding and lotions ; tying spermatic artery ; castration. — Varicocele : resembles 
circocele. — Produced by same causes. — Cooper's operation for its relief. 

This is a varicose enlargement of the spermatic veins, and usually is confined to 
the spermatic cord. It generally commences by the side of the testis, at the most 
dependent part of the cord, and seldom extends within the inguinal ring. There is 
a sense of weight in the scrotum ; an irregular knotty feeling, often presenting a 
sensation under the fingers which has been compared to a bundle of ropes, or earth- 
worms. The vessels, in truth, are so enlarged, that they can readily be distinguished, 
and this resemblance to worms, therefore, is not at all fanciful. 

A recent circocele is free from positive pain, but when pressed, there is a little 
tenderness. In the advanced stages of the disease, the pain becomes severe, reach- 
ing sometimes to the back and loins. 

Sometimes it does not go beyond the first stage, but is confined to the spermatic 
cord and epididymis, and will remain in this condition for many years without any 
perceptible change. 

CAUSE OF CIRCOCELE. 

Whatever prevents a free return of the blood into the general current of the 
circulation, may give rise to this affection. This may be a relaxation of the coats of 
the veins themselves ; a tumor situated in such a position as to make pressure upon 

333 



334 



CIRCOCELE. — TREATMENT. 



the cord, a truss worn for hernia, long standing, walking, riding on horseback, violent 
efforts of the body, great exertions of the lungs, and whatever else has the effect of 
interrupting or augmenting the circulation in the parts. 

It has been mistaken for omental hernia. The history of the case will guide us 
in distinguishing between them. In circocele, the swelling, in the first instance, is 
not noticed at the abdominal ring. If the patient be laid in a horizontal posture, and 
pressure applied, the swelling will disappear. By placing, now, the finger firmly 
upon the ring, with so much force as to impede the circulation, and requesting the 
patient to rise, if it be circocele, the swelling will return with increased size — but if 
it be hernia, no perceptible change takes place. 




Operation for tying the spermatic artery. 



TREATMENT. 



Should the disease be produced by the pressure of a truss, the remedy, of course, 
is to remove or so adjust it to the inguinal ring, as to relieve the cord. If by a 
tumor, all our efforts must be directed to its absorption, which frequently may be 
attained by frictions of mercury or iodine made directly over the spot. The scrotum 



VARICOCELE. 885 

is to be placed in a suspensory bandage, to favor the return of the blood ; and some- 
times, particularly if there be any tendency to inflammation, leeches or scarifications 

will prove of much service. The patient should observe the horizontal posture, avoid 
all physical efforts, and apply cold lotions. 

The operation of tying the spermatic artery, has been successfully performed by 
Dr. Jameson, of Baltimore ; and it is one which commends itself to the profession, 
after all other remedies have failed.* The danger which may be apprehended of a 
loss of function in the testicle, is not sustained by the results; no perceptible change 
in this respect, ensuing from the operation. [See cut on page 334.] 

When the pain and general distress have become very intense, the operation of 
castration has been done, affording immediate relief, and ending in a complete cure. 
It need scarcely be observed, however, that this proceeding should never be resorted 
to in ordinary cases. Should a surgeon be so enterprising as to adopt this remedy 
upon slight pretexts, he will, in the end, most certainly lose more reputation than he 
can hope ever to acquire by it. 

Varicocele is an affection, closely resembling circocele. It is produced by the 
same causes, but it is more especially an enlargement of the veins of the scrotum. 
Usually, it is a very trifling disease ; occasionally, however, it becomes so inconve- 
nient as to demand surgical attention. The same remarks which have been made 
respecting the treatment of circocele, apply to varicocele. Sir A. Cooper several 
times successfully performed the operation of removing part of the scrotum, by 
which he furnished the testicle with a better support, and lessened the inconve- 
niences that the patient suffered from. 

* See American Medical Recorder, for April, 1825. 



CHAPTER XXIX. 

DISEASE OF THE PROSTATE GLAND. 

The Prostate Gland, where situated. — Its diseases. — Causes. — Whatever may produce inflammation 
of the inner extremity of the urethra, may be a cause. — Symptoms. — Pain and general uneasiness ; 
strong desire to urinate ; some of the urine remains in the bladder; the gland may be felt enlarged 
by introducing the finger in the rectum. — In acute inflammation, other symptoms : abscess ; termi- 
nation. Treatment: when acute, antiphlogistically ; abscesses should be opened. — Retention of 
urine, and the mode of relieving it. — The catheter may be retained in the bladder. — Operation by 
puncture. — Tonics. — Change of air; balsams; opium. — When chronic, how treated. — Iodine. 
In persons advanced in life. 

The prostate gland is situated at the neck of the bladder, and at the beginning of 
the urethra, embraces it, and, although contrary to what, from its position, would be 
anticipated, is often subject to disease, which may be acute or chronic. The latter 
species of inflammation is by far the most common, and occurs most frequently in 
men who have reached the advanced stage of life. 

The ordinary causes of this disease, are stricture, gonorrhoea, excessive sexual 
indulgence, onanism, the application of cold to the body, gout, rheumatism, injuries 
inflicted on the perinseum, calculi, irritating urine, &c. In fine, it would appear that 
whatever is capable of producing inflammation of the urethra at its inner extremity, 
may give rise to an affection of the prostate. 

The symptoms which accompany it, are a frequent and almost irresistible incli- 
nation to empty the bladder ; great uneasiness and pain at the neck of that organ, 
extending through the perinaeum to the glans penis, along the course of the urethra ; 

336 



DISEASE OF THE PROSTATE GLAND. 



887 



pain shooting along the thighs, and backward to the loins ; sometimes in the hypo- 
gastrium. In the rectnm there is a seDse of obstruction, and when the patient goes 
to stool there is much increase of his suffering, and the feeling which remains is as 
if the bowels had not been completely emptied. There generally is a partial reten- 
tion of urine, which issues with little or no force, is flattened or broken, and win,, 
the obstruction is great, it mereh/drops between the legs. Sometimes the retention 
is complete, and no effort of forcing can expel a drop, but only has the effect of 
closing more tightly the valve, formed by what Home called the third lobe of the 
gland, over the vesicle orifice of the urethra. If the patient be not relieved of this 
condition, by the timely application of remedies, all the train of symptoms that have 
been described in the Chapter on Stricture, ensue. There is often a dribbling of 
urine, and, when the patient is lying in bed, it is most distressing. A certain quan- 
tity of urine, varying from one to several ounces, is retained, after the patient has 
made water, and this imparts to it, at all times, an alkaline or ammoniacal character, 
from the stagnation which takes place within the bladder. 

If the finger be introduced into the rectum, the gland will be found sometimes, en- 
larged to several times its natural size. The 
left side, especially, seems disposed to this in- 
crease. [See the Cut.'] 

Such are the usual local symptoms that ex- 
hibit themselves in a diseased prostate. If the 
inflammation be acute, there are, also, added 
certain other characteristic signs. The uneasi- 
ness of the part is increased when pressed either 

through the rectum or on the perinseum ; there ffge d Prostate Gland. 

is much heat and a great sense of weight, tension and fullness over the region of 
the gland. There is severe tenesmus, and a constant desire to urinate and go to 
stool. A throbbing is experienced, such as is common in phlegmonous inflammation, 
wherever it may be situated ; a feeling of chilliness or distinct rigors occur, suc- 
ceeded by fever, with all the other disorder of functions incident to pyrexia. 

The acute inflammation of the prostate, ordinarily terminates in from seven to 
fourteen days, either by resolution, suppuration, or by assuming a chronic condition 
— never, so far as I know, by gangrene. 




338 DISEASE OF THE PROSTATE GLAND.— TREATMENT. 



TREATMENT. 

If the disease be acute, and the patient young and phlethoric, the most energetic 
antiphlogistic measures are to be resorted to. Blood may sometimes be abstracted 
from the arm, but always leeches should be applied to the perinsenm. Emollient 
poultices, hip-baths or hot fomentations, narcotic injections, brisk saline purgatives, 
and, in severe cases, antimonials, to produce nausea, may all be usefully employed. 

Should we fail to effect resolution, and there seems to be a certainty of the forma- 
tion of matter, then the antiphlogistic treatment is no longer to be pursued, but all 
our care should be given to facilitate suppuration, and detect its earliest signs. 
When this has taken place, we shall probably be able to discover an obscure fluctu- 
ation, denoting the existence of an abscess. 

When abscesses occur in this situation, it is very rare that they are in the glan- 
dular parenchyma, but, rather, in the cellular tissue enveloping it. When this con- 
dition exists, we have an affection of a grave character to combat, as the gland may 
be completely infiltrated with pus, and there is no way, either through natural or 
artificial means, of removing it. Suppuration, therefore, almost necessarily advances ; 
the general health is more and more impaired ; irritative fever rises ; and the func- 
tion of nutrition is so indifferently performed, that the patient, ultimately, may sink 
from debility. 

Some surgeons, and among them Sir Benjamin Brodie, recommend that so soon 
as pus is known to have formed, the abscess should be opened. The use of the 
bistoury, I believe, generally, may better be dispensed with. If there be a decided 
tumor in the perinfleum, giving the idea that pus is making its way towards the skin, 
through all the deep tissues, then, indeed, it would be proper, without any delay, to 
open with the knife. But, as abscesses nearly always, enlarge towards the nearest 
mucous or cutaneous surface, we may expect that the pus will find its way to the 
bladder or urethra, and thus obtain an exit from the body, through the urinary canal. 

It may happen that, while we are treating the inflammation, it wiil be necessary 
to relieve the patient from a retention of urine. In truth, in all these cases, it is ad- 
visable to remove the water with the catheter, although, there should not be an abso- 
lute necessity for such a practice. The catheter employed, had better be rather 
small, with a wire fitted to it; and this should be bent to a shape a little moro 



DISEASE OF THE PROSTATE GLAND.— TREATMENT. 

crooked, than is demanded for other obstructions in the urethra. When the instru- 
ment is introduced, it is as well to permit it to remain in that position, as it puts the 
patient to no particular inconvenience, and it is thus always ready for use, without 
the necessity of passing it on each occasion that the bladder requires to be evacuated. 

The case may be worse than we have described, so that instead of a partial there 
will be a total retention of urine. Such a condition is to be remedied, if possible, 
in the usual way, but if all efforts fail to introduce the catheter, we must have re- 
course to one of the methods recommended in the Chapter on Stricture, consisting 
in puncturing the bladder through the rectum, above the pubis, through the peri- 
nseum, or by passing an instrument along the urethra to the prostate, when the 
gland is to be perforated by forcing it directly through. [See the cut representing 
this operation, under the head of Stricture .] 

The patient ought to be kept in a recumbent posture, with his hips slightly ele- 
vated ; and all the methods are to be observed which will conduce to diminish inflam- 
matory action. 

When the matter has been discharged from the abscess, our care must be to keep 
up the strength, and improve the general health by every possible means. Change 
of air may be desirable, particularly to the sea-side, quinine, iron, sarsaparilla, the tur- 
pentines and balsams — in small doses, so that they may produce very slight action on 
the kidneys — are often useful, and should be employed. Opium, in such cases, is 
also a very valuable drug, and should not be neglected, as it lessens the irritation, 
from which the patient will, otherwise, greatly suffer. 

If the inflammation be of the chronic kind, the treatment, is nearly the same 
as in the acute, except that there is no occasion for reducing the patient's strength. 
The same local applications, including leeches, are useful ; and, should there not be 
suppuration, the iodide of potassium, or iodine in some other form, may be admin- 
istered, both as a suppository, and by the month. By this means we may fre- 
quently succeed in removing the enlargement, and restoring the patient to a very 
comfortable state of health. 

When the enlargement occurs in a person of advanced age, there is but little hope 
of doing more than to afford temporary relief. The suffering may be greatly reduced, 
by frequently introducing the catheter and drawing off the water. This should be 
done as often as three or four times a day. By neglecting this plan, the patient will 
be constantly harassed by a desire to urinate, as he is never able, unaided by arti- 



340 



DISEASE OF THE PROSTATE GLAND. — TREATMENT. 



ficial means, to empty, completely, the bladder ; and, consequently, he necessarily 
experiences the sensation of distention. 

Most persons with whom such a necessity exists, may be instructed to introduce 
the instrument for themselves ; and, in a short time, will acquire much readiness in 
doing it. They will therefore, be, for the remainder of their existence, subject to 
some inconvenience, and slight suffering ; but, nevertheless, may enjoy life, and will 
finally die of some other disease. 




Douche Bath. 



This drawing represents the kind of douche bath which I have had constructed for the treatment of 
seminal diseases and affections of the anus. The same kind of application of water can be very easily 
made in any house where the Croton water is introduced. 



APPENDIX. 



FORMULARY FOR VENEREAL DISEASES. 



SYPHILIS. 



PILLS. 



ft Hydrarg. bi-chlorid. gr. ^. 
Ext. Cinchonas, gr. iv. 
Ext. Opii, gr. ss. 
F. M. Make a pill. The dose is from two 
to three a day. This pill, with the exception of 
a slight modification, was recommended by 
Dupuytren. According to his observation, the 
cinchona and opium, modify, beneficially, the 
action of the sublimate. 



ft Pulv. Althaeas, §iv. 
Proto-chlor. Hydrarg. 
Resinae Guaiaci, aa " 3 i j . 
Syrupi Cydoniae, q. s. 
Formed into four grain pills, the dose of which 
is from four to six a day. These are recom" 
mended by M. Alibert. 



ft *Unguent. Hydrarg. 3ij. 
G-lycyrrhizae pulv. q. s. 
This is to be made into one hundred and forty- 
four pills. They arc employed by M. Fouquier, 

* This ointment is formed of equal pails of mercury and 
lard. Vide Pliarm. Gall. 



341 



who thinks that they irritate the stomach less than 
"any other mercurial preparation. The dose may 
be carried to six a day. Along with these pills, 
he sometimes directs the use of baths and dia- 
phoretic drinks. 



ft Hydrarg. proto-iodidi. 

Ext. Lactucee, aa 3ss. 

Opii, gr. ix. 

Guaiaci, fj. 

F. M. Divide into thirty-six pills. In obsti- 
nate cases, that are accompanied with much 
induration of the tissues, two or three grains of 
powdered leaves of conium may be added. 
These pills are to be taken at night, four or fivo 
hours after the last meal. 



ft Hydrarg. bi-chlorid. gr. ij. 
Solve in aqua dcslill. q. s. 
Opii, gr. ij. 
Mel lis, gr. xx. 

Mica: panis, q. s. ut fiant pilulaB No. xl. 
Thin is a formula of which the Germans entei- 
tain a very high opinion. Hnfeland says thai 
corrosive sublimate may be used without detri 
ment, and for a long lime, if given in pills an 



.342 



SYPHILIS. — PILLS. 



with a mucilaginous vehicle, in order that it may 
dissolve slowly, which prevents nausea, colic and 
diarrhoea. It is proper to remark, he adds, that 
corrosive sublimate is apt to affect the lungs, and, 
therefore, in persons of a phthisical disposition, is 
contra-indicated. The dose of the pills, is six, 
ten, and even twelve, morning and evening. 

R- Hydrarg. oxidi rubri, gr. j. 
Antimonii crud. gr. xl. 
Ext. Glycyrrhizee, q. s. ut fiant pilulae 
No. lxxx. 

Dose : ten at bed time, and in the course of 
time, in obstinate cases, twice this number may 
be given. Or the one-half of this quantity may 
be given in the morning, and the other half in 
the evening, after eating. This latter method 
of administration I prefer. The red precipitate 
is a very powerful preparation of mercury, and 
in this country has not been much employed 
internally. The form of it prepared by calcina- 
tion, I like better than that prepared with nitric 
acid. It will sometimes do wonders when all 
the other forms of mercury have failed. 



R Hydrarg. proto-chlorid. 

Antimonii sulph. precip. aa 3j. 
Guaiaci i-esinae pulv. 3ij. 
Syrupi, 3j. 
F„ M. Divide ir *"lls of five grains each, and 
give one, two or three times a day. It may be 
useful, if they act too freely on the bowels, to 
combine one fourth of a grain of opium with 
each pill. 



DECOCTIONS. 



Ptisan of Feltz. 
R- Rad. Saisaparillas incis. ^iij. 
Gum. arabic. 3ss — 3ij. 
Antimonii sulph. ^iv. 
Aquae, Ibvj. 
Boil to one half; the antimony being enclosed 
in a bag and suspended in the fluid. Three or 
four wine-glasses of it may be given daily, care- 
fully observing the susceptibilities of the patient. 
This medicine should be given, generally, for 
not less than two months. 



The patient's food should consist of roast or 
boiled meat and vegetables, and salt must be 
abstained from to prevent the decomposition of 
the antimony that is suspended in the decoction. 
It has been thought by some persons that no anti- 
mony is yielded to the mixture, but that it gives 
to it a small quantity of arsenic. 

. Decoction of Zitman. 

NUMBER I. 

R- Rad. Sarsaparillae, §xij. 

Aquae, Ifcij. 

Sacchar. alumin. §iss. 

Hydrarg. proto-chlorid. §ss. 

Cinnabaris, 3j. 

Pol. Sennas, ^iij. 

Rad. Glycyrrhizae, ^iss. 

Seminis Anisi, 

Seminis Feniculi, aa ^x. 
The sarsaparilla and water should be boiled 
together a quarter of an hour, and then the sac- 
char, alumin. calomel and cinnabar added, en- 
closed in a linen bag, and all boiled down to one 
third. The other ingredients being now added 
and allowed to stand for a short time, it should 
be strained for use. 

This is termed the strong decoction. The 
weaker is made as follows : — 

NUMBER II. 

R- Rad. Sarsaparillae, § v j- 

Aquae, §xxiv. 
Boil and add, 

Cort. Citr. 

Cort. Canell. 

Sem. Cardamomi minoi*. 

Rad. Glycyrrhizae, aa 3iij. 
On the first day the patient must take a pur- 
gative ; each morning he is to take half-a-pint of 
No. 1, to be drunk warm, and keep his bed. In 
the afternoon a pint of No. 2 : again half-a-pint 
of No. 1 in the evening — the two latter doses to 
be taken cold. This is to be continued for four 
days, on the fifth a purgative is given. The 
same treatment is then to be repeated for four 
days, and again followed by a purgative. After 
the interval of a week, if it be required, the treat- 
ment must be resumed in the same manner as in 
the first instance. The diet should be rigid. 



SYPHILIS.— DECOCTIONS. 



• ; t l 



Decoct inn Album. 
i; Pulv. Cornu cervi, ij. 
Medullas Ponis, 3vj. 
Gum. Arabic. 3ij. 
Sacchar. alb. 
Aqua, ;\\ij. 
Mix well in a mortar, boil all together hall'-an- 
hour in a covered vessel. This will supply a 
pint of the decoction. This is used externally, 
and also internally as a vehicle. 

R Had. Sarsaparillae, 

Rad. Srailacis China?, 

Ligni Guaiaci, aa 3ss. 

Sassafras, 3ij. 

A qua?, Ibij. 
This should be boiled to one half. Dose, two 
table-spoonfuls three times a day. It is perhaps 
the mostuseful when it is given in quantities and 
under circumstances calculated to produce some 
perspiration. 



Decoction Mczereum. 
R Rad. Mezcrei, 3ij. 

Rad. Glycyrrhizae, ^ss. 
Aquas, ibiij. 
Boil with a gentle fire down to two pounds 
and strain. In nodes and pains this is very use. 
ful. The dose is from four to eight fluid ounces 
three times a day. 

Dccoctum Pollini. 
R Rad. Sarsaparillae, fj. 
Stipit. Dulcamara?, 3"ss. 
Pulv. Antimonii crud. 3j. 
Boil in two pints of water to one and a half, 
and add, 

Fol. Sennae, 3ss — 3j. 
Boil, strain and add, 

Syrupi Fumariae, fj. 
All to be taken in one day. 



SYRUPS. 



R Rad. Sarsaparillae concisae, 
Ligni Guaiaci, aa Ibj. 
Aquae Fontanae, Ibxij. 
Sacchari, 
MelHs albi, aa Ibiss. 



1 [aving, in tin- ii: i in itonco, m ide the d( 
tion with the guaiacum and iai nparilla, bj boil 
ing until the Quid is reduced one half, the Bagar 
and honey are to be added and dissolved. Two 
table-spoonfuls of this may I"- riven fbi a do.su 

three times ;i day. 



R Rad. Sarsaparillae, -\xx. 
Aquas, Ibxxiv. 
Infuse for twenty -lour hours, and then hoil 

down to ll.viij. Repeat this operation two more 
times, strain and mix the three decoctions, then 
add — 

Flor, Borag. off. 

Flor. Rosar. alb. aa 3 i j . 

Fol. Senna?, 5'ss. 
Boil down to one-half, strain and add, 

Sacchar. alb. ct Mel. aa lbij. 
Two to four ounces may be administered 
daily. It is especially suitable for subjects who 
are di-poscd to constipation. When it purges 
moderately it may be advantageous, but if it 
gripes or produces diarrhoea, its use must be sus- 
pended. 



R Sarsaparillae concisa?, Ibj. 

Ligni Guaiaci, ^iss. 

Flor. Rosar rub. 

Fol. Sennae, 

Rad. Glycyrrhizae, aa fj. 

01. Sassafras, 

01. Auisi, aa M iiss. 

Sacchar. alb. Ibiv. 

Alcohol, dilut. O v. 
Macerate the sarsaparilla, guaiacum, roses, 
senna and liquorice root in the alcohol for four- 
teen days; then express and filter through paper. 
Evaporate the tincture by means of a water 
bath, to four pints an 1 a half, then add the sugar 
and dissolve so as to form a syrup. With this, 
when cold, mix the oils previously triturated 
with a small quantity of the syrup. 

A syrup prepared after this method, probably 
possesses much more virtue than that made by 
boilin"-. The dose is a table-spoonful three or 
four times a day. 

To any of these syrups may be added one of 
the preparations of mercury, particularly the cor- 
rosive sublimate. Ricord prefers, in such cases, 



344 



SYPHILIS. — OINTMENTS : SOLUTIONS. 



the cyanide of mercury, four grains to the pound, 
which is less liable to decomposition than the 
deuto-chloride. A tea-spoonful should he given 
night and morning, increasing, gradually, to half 
an ounce a day. If the bowels are too much 
purged, eight grains of the extract of opium 
may be added to the pound. 



OINTMENTS. 



Unguent. Opiatum. 

R Axung. ibj. 

Tinct. Opii, lj. Mix. 



Ceratum Plumbi. 
R Cerat. Sim pi. 5j- 

Liquor. Plumbi di-acetatis, 3j. Mix. 



Unguent. Hydrarg. Opiat. 
I5L Unguent, opiat. 

Unguent, hydrarg. aa |j. Mix. 
Used in cases where the mercurial ointment 
is too irritating. 



Unguent. Hydrarg. Chlorid. 

R Hydrarg. proto-chlorid. gr. vj. 
Cerat. Opiat. 3ij. Mix. 



Unguent. Belladonna. 

R Ext. Belladonnas, 3ss. 
Axung. fj. Mix. 



Unguent. Hydrarg. Iodid. 
R Hydrarg. Iodidi, 3j. 
Axung. ^j. Mix. 
The quantity of the iodide may be increased 
to two drachms, if too great irritation be not 
produced. 



Mel. Hydrarg. Iodid. 
R Mellis, |iss. 

Hydrarg. iodid. 3j. Mix. 



Unguent. Hydrarg. Oxid. Rub. 
R Hydrarg. oxid. rub. fj. 
Unguent, sinvpl. §viij. 



The mercury is to be added to the ointment 
previously softened over a gentle fire, and mix 
them. 



Unguent. Hydrarg. Fort. 
R Hydrarg. §iv. 

Axung. ^iij. Mix. 



Unguent. Hydrarg. Mit. 
R Hydrarg. fj. 

Axung. ^ij. Mix. 



Unguent. Potasses Iodid. 

R Potassas Iodidi, 3ss. 
Axung. ^j. Mix. 
When it is intended to introduce mercury into 
the system by means of frictions, I recommend 
that a mass of ointment, about half the size of a 
hazel-nut, be rubbed in every other night, either 
in the axillae, the popliteal space, or over the 
cervical glands ; and also on blotches, and around 
ulcers, wherever they may be situated upon the 
body. 



SOLUTIONS. 

Solutio Opiata. 
R Aquae Lactucae, f viij. 

Ext. Gum. Opii, 3j — ij. Mix. 
In gangrenous affections, when the irritability 
increases, the quantity of opium must sometimes 
be decreased. 



Solutio A?nmonia>. HydrocM. 
R Aquae, fviij. 

Ammoniae Hydrochl. 3ij. 
Solve. Particularly useful in resolving the 
inflammation and swelling of buboes. 



Tinrturce lodini dil. 
R Aquas Deslill. fiij. 

Tinct. lodini, 3j. Mix. 
This tincture may be made stronger if it is 
desirable. It is employed in the treatment of 
buboes, hydrocele, etc. 



SYPHILIS. — GARGLES: FUMIGATIONS. 



845 



Soda Chlorinates dil. 

15 Liquor. Soda' chlor. ^ij. 
Aquae, • : .vj. Mix. 
The quantity of soda may be increased till a 
bl tingling sensation and heat are produced. 
I sed in tin 1 treatment of mucous tubercles. 



Solutio JL/Jrarg. Bi-chlorid. 
H Hydrarg. bi-chlorid. gr. xx. 
Aquae destill. |j. Solve. 
For cauterizing vesicated surfaces in the treat- 
ment of buboes. 



5»J- 



Vtnutn Aromaticum. 
R Spirit. Lavandulae comp. 
Vini rubri, Ibj. Mix. 
To this may be added, when considered not 
sufficiently astringent, a few grains of tannic acid 
to an eisrht ounce mixture. 



Vinum Aromaticum c. Opn. 
R Vini Aromatici, fviij. 
Ext. Opii, 3ss. Solve. 
Employed as dressings for chancres and buboes. 



GARGLES. 



Mercurial Gargle. 
R Fol. Conii maculat. fss. 
Aquae, fbiss. 
Fiat decoctio, et adde, 
Mellis, $ij. 

Deuto-chlorid. hydrarg. gr. v. 
Tinct. Opii, 3j. Mix. 



R Sodae Boratis, 3iss. 
Tinct. aa Myrrhae, 
Mellis, fiss. 
Aquae Rosarum, ^iv. 
Fiat garg. May be used in ptyalism, or scor- 
butic affections of the gums. 

R Plumbi Acetatis, 3j. 
Syrupi simpl. §j. 
Decoct. Hordei, lb j. 
Fiat solut. In mercurial sore mouth. 



I: a i genti Nlti atis, gr, viij. 
Aquas doatill. 
V. solutio. 

Corrosive Sublimate and lAme-water. 
I! I [ydrarg. bi-chlorid. gr. j. 
Aquae Calcis, 
!'. Bolutio. Tins may be advantageously em- 
ployed in venereal ulcers of the throat. 



Alum in is it Potassce Sulph. 
li Aquae Rosarum, z ,\ij. 

Alum, et Potassae sulph. 3j. 
Mellis, =j. 
solutio. In apthous affections, and mercu- 
rial stomatitis, when there is not great inflam- 
mation. 



[• 



Acidulous Gargle of Cinchona. 
R Cinchonae, 3ij. 
Mellis, 3j. 

Acidi hydrochlorici, 3ij. 
Aquae, Ibj. 
This is a very useful gargle in mercuiial sore 
throat, and especially if there be a tendency to 
<ran<nene. 



R Zinc sulph. iij. 
Mellis, 3j. 
Tinct. Myrihae, ?ij. 
Spirit. Vini Gallici, ^ij. 
Aqua- Rosarum, ^vj. 
F. solutio. Useful as a gargle, to be used 
occasionally, when there is excessive salivation. 

R Liquoris Sodas chlorinatae, 3j. 
Aqua? destill, 3j. Mix. 
This is useful in syphilitic and scorbutic affec- 
tions of the gums. 



FUMIGATIONS. 



R Sulphureti Hydrarg. rubri, 3iss — iij. 

This is to be placed in a red-hot iron dish, or 

a heated shovel, and the fumes inhaled as they 

arise. These fumes consist of sulphurous acid 

gas and mercurial vapor. The sulphurous fumes 



•346 



SYPHILIS. — BATHS: PLASTERS: CATAPLASMS. 



are necessarily very irritating to the lungs, and 
therefore, especially to those in whom these 
organs are weak, very objectionable. A better 
plan is to confine the body of the patient in a 
close cover or box, leaving the head and face in 
the open air, a^ is done in sulphur fumigation. 
Fumigation is employed in venereal ulcers of 
the nose and throat, when it is important to get 
the system under the influence of mercury as 
speedily as possible. It may be added, that the 
black or grey oxide of mercury is preferable to 
the cinnabar, as neither contain sulphur, and 
hence the fumes may be inhaled without injury 
to the organs of respiration. 



BATHS. 



When baths are employed for diseases of 
the skin, syphilitic or otherwise, they are com- 
monly used warm. The temperature of the 
water may be graduated, to some extent, by the 
constitutional susceptibility of. the patient. If he 
is feeble, and much debilitated, it is necessary 
that the temperature should be higher than if the 
patient is vigorous. As a general rule, the bath 
should be tepid, ranging from 75° to 85° of 
Fahrenheit. 

The bath of simple water is most commonly 
used. When I am applying mercurial frictions 
on the skin, it is my practice usually, to prescribe 
a tepid bath onr° "v twice a week, by the assis- 
tance of which, I think I obtain the constitutional 
effects of the ointment more readily than when 
it is omitted. 

Gelatinous baths, much in vogue in the French 
hospitals, are made by adding from one to two 
pounds of glue or isinglass to the usual quantity 
of water for a bath. 

Alkaline baths are made by adding two pounds 
of sub-carbonate of potassa to the necessary 
quantity of water. 



Mercurial Bath. 
R Bi-chlorid. Hydrarg. fss. j. 
Aquae, q. s. 



ESCHAROTICS. 



The 



common caustics most usually em- 
ployed, are the nitrate of silver and the potassa 



fusa. Another caustic that is very powerful and 
frequently used, especially on the European con- 
tinent, is the Vienna paste, v\hich is made by 
adding to six parts of caustic potassa, five of 
quick-lime. When required for use it should be 
made into a paste by moistening it with a suffi- 
cient quantity of alcohol. 



• PLASTERS. 

Emplast. Conii c. Plumbi Iodid. 
R Emplast. Conii, 3j. 

Plumbi Iodid. §j. Mix. 
This is used in buboes, and especially in chro- 
nic engorgements of the testicles. If twenty 
grains of tartrate of antimony be sprinkled upon 
a plaster of emplast. conii of the size of the hand, 
it forms an excellent excitant where the buboes 
are indolent. 



Emplast. Ammoniaci c. Hydrarg. 
R Ammoniaci, §viij. 
Hydragyri, §iss. 
Ol. Olive, 3ss. 
Sulphur, pulv. gr. iv. 
The oil is to be heated and the sulphur gra- 
dually stirred in till they unite ; then rub the 
mercury with them until the globules disappear ; 
lastly, gradually add the ammoniac previously 
melted, and mix the whole together. 



CATAPLASMS. 



Cataplasm. Fcrmenti. 
R Tritici Farinas, Ibj. 

Cerevisias Ferment. § x. 
Mix, and expose it to a gentle heat until it 
begins to rise. 

Cataplasm. Lini. 
R Aquae bullient, Oj. 

Seminis Lini, q. s. to produce a proper 
consistence. 



R Cataplasm. Lini, Ibj. 

Unguent. Resinosi, § ss — j. 
This poultice may be employed with advan- 
tage when the intention is to bring, quickly, a 
phlegmonous tumor to suppuration. 



GONORRHOEA.— PILLS: MIXTURES: INJECTIONS 



Ml 



GONORRHOEA. 



PILLS. 

R- Copaibae bals. f ij. 
Magnes. Ustae, 3ss. 
Mix them, and set the mixture aside until it 
concretes into a pilular mass, which is to be 
divided into two hundred pills. It is important 
to the succ3ss ef this mixture that the magnesia 
be recently prepared. 



R- C amphorae pulv. 3ij. 
Ext. Gum. Opii, gr. viij. 
Mucilag. q. a. 
Mix and divide into sixteen pills. Given in 
doses of two or three every evening, to allay irri- 
tation in the neck of the bladder, chordee, &c. 



MIXTURES. 



R Copaibae resin. 
Alcohol. 

Syrup. Bals. Tolut. V- aa fj. 

Aquae Menth. pip. 
Aquae Flor. Aurantii, 
Sp. ^Etheris Nitrici, 3ij. Mix. 
Dose, from two to six table-spoonfuls daily. 
This is a formula of Chopard, that is much cele- 
brated in France. 



3 



F. M. 

a dose. 



R Copaibae bals. 

Sp. Athens Nit. aa ^ss. 
Pulv. Gum Arabici, 

Sacch. alb. aa 3j, 

Sp. Lavand. comp. 3ij. 

Tinct. Opii, 3j. 

Aquae destill. ^iv. 

A table -spoonful three times a day for 



\], Pulv. Cubebae, lj. 

Sulphat. Alum, et Pot. 3j. 
Pulv. Gum. Arabic. 

Sacchar. alb. aa 5 33 - 

Aquae Mhnth. pip. ^xij. 
F. M. secundum artem. Dose, three table- 
spoonfuls four times a day. 

R Copaibae bals. 
Tinct. Cubebae, 

Catechu, 

Sp. ^Etheris Nitrici, aa ^j. 
Tinct, Opii camphor, ^iss. 
Tulv. Gum. Arabic. 

Sacchar. alb. aa §ss. 

Aquae Meuth. pip. ^ivss. 
F. M. Dose, a table-spoonful two or three 
times a day. 

Capsules, containing copaiba and the oil of 
cubebs, have proved very useful in my practice. 

INJECTIONS. 

R Aquae Rosar. %iv. 
Sulph. Zinci. gr. x. 
Tinct. Opii, 3ss. Mix. 
To be injected several times a day. 



R Aqua? Rosar. ^iv. 

Alum, et pot. sulph. gr. x. Mix. 
To be used frequently. 

R Aquae destill. %iv. 

Plumbi acet. 3j. Mix. 

R Zinci sulph. 

Plumbi Acet. aa 3iss. 
Aquae destill. ^viij. 
Solve. Filter, and use for injection. 



348 



GONORRHCEA. — INJECTIONS. 



R Vini rub. §vj. 

Acidi Tannic, gr. xviij. 



Mix. 



R Aquae destill. fiv. 

Argent nit. gr. j. Mix. 
Some surgeons employ as much as a grain to 
the ounce. If a very powerful effect be desired, 
with the view of cauterizing, ten to thirty grains 
to the ounce of water may be used. 



R Aquae destill. ^iv. 

Ferri iodidi, gr. ij. Mix. 
The quantity of iron may be increased, to as 
much as ten grains to the ounce of water, but as 
there is danger of irritation, much care is re- 
quired. 



R Querci cort. §jj. 
Aquae, Oj. 

Boil down to half-pint, strain and add twenty 
grains of alum. 

Any one of the foregoing injections may be 
used for the vagina, but generally require to be 
made somewhat stronger. 

It ought to be observed, that to use injections 
most successfully, they should be employed as 
often as every hour or two. There is almost an 
endless variety of them. Those which I have 
found to be most useful I have selected ; and I 
live in hope of yet being able to find something 
when locally applied to the urethra, that will 
prove a perfect specific for Gonorrhoea. 



t^NOTICE.^ 

/ omitted, unintentionally, to acknotvledge in the Preface, that the Chapters describing the Male and 
Female Organs of Generation, have been selected mainly from BELL, with such alterations only, as 
seemed to be necessary to a work of this nature. 



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